Provider Demographics
NPI:1033213392
Name:DAHL, PATRICK ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:ROBERT
Last Name:DAHL
Suffix:
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 5859
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92838
Mailing Address - Country:US
Mailing Address - Phone:714-525-3500
Mailing Address - Fax:714-525-3588
Practice Address - Street 1:301 W BASTANCHURY ROAD
Practice Address - Street 2:SUITE 245
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835
Practice Address - Country:US
Practice Address - Phone:714-525-3500
Practice Address - Fax:714-525-3588
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75823207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
W13925Medicare ID - Type Unspecified
F44691Medicare UPIN