Provider Demographics
NPI:1730743998
Name:DALLEY, MATTHEW
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:DALLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 FOXFIRE DR
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-3012
Mailing Address - Country:US
Mailing Address - Phone:407-496-8671
Mailing Address - Fax:
Practice Address - Street 1:11234 ANDERSON STREET
Practice Address - Street 2:GME OFFICE WESTERLY SUITE C
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-4085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME157225207P00000X
CAA178117207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program