Provider Demographics
NPI:1124091475
Name:DALTON, WILLARD T JR (MD)
Entity type:Individual
Prefix:
First Name:WILLARD
Middle Name:T
Last Name:DALTON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6037
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70361-6037
Mailing Address - Country:US
Mailing Address - Phone:985-873-4235
Mailing Address - Fax:985-851-4307
Practice Address - Street 1:8166 MAIN STREET
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360
Practice Address - Country:US
Practice Address - Phone:985-873-4141
Practice Address - Fax:985-851-4307
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD08126R207ZH0000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1389650Medicaid
LA1389650Medicaid
LA4M8417627Medicare PIN
LA5J994Medicare ID - Type Unspecified