Provider Demographics
NPI:1063420750
Name:LEA, DALLAS A (MD)
Entity type:Individual
Prefix:DR
First Name:DALLAS
Middle Name:A
Last Name:LEA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1400 SPRING ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-2735
Mailing Address - Country:US
Mailing Address - Phone:301-495-3742
Mailing Address - Fax:301-495-3743
Practice Address - Street 1:1400 SPRING ST
Practice Address - Street 2:SUITE 400
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-2735
Practice Address - Country:US
Practice Address - Phone:301-495-3742
Practice Address - Fax:301-495-3743
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD591362081P0004X
DCMD335232081P0004X
TXL33752081P0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H68197Medicare UPIN
7133661OtherAETNA NON HMO
258880OtherKAISER
1327851OtherAETNA HMO
5460-0109OtherBC BSNCA
24101OtherCHARTERED
750640OtherNCPPO
DC038326200Medicaid
H68197Medicare UPIN