Provider Demographics
NPI:1184650566
Name:NANCE, DALE (MD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:
Last Name:NANCE
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 1084
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-1084
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:912-045-7933
Practice Address - Street 1:340 EISENHOWER DR STE 1305
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-1607
Practice Address - Country:US
Practice Address - Phone:706-975-5993
Practice Address - Fax:912-304-5793
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD263242085R0202X
GA0484482085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR003830023OtherREGENCE BC BS
WA8448136Medicaid
OR273838Medicaid
WA8448136Medicaid
ORP00281151Medicare PIN
A05247Medicare UPIN