MEDICARE: LESLIE W DALTON III MD

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	H3997	TX

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1386647022
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE W DALTON III MD

Provider Business Mailing Address
First Line	:	PO BOX 164106
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78716-4106
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	901 W BEN WHITE BLVD
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704-6903
Country	:	US
Telephone Number	:	512-448-7100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/26/2005
Last Update Date	:	04/23/2009

901 W BEN WHITE BLVD , SOUTH AUSTIN HOSPITAL PATHOLOGY DEPARTMENT
AUSTIN, TX
78704-6903

Practice Phone: 512-448-7100
Practice Fax: 512-416-6409