Provider Demographics
NPI:1225106602
Name:EKSTRUM, DALE ETHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:ETHAN
Last Name:EKSTRUM
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 1:117 WEST BUNNY AVENUE
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-2805
Mailing Address - Country:US
Mailing Address - Phone:805-735-4292
Mailing Address - Fax:805-735-4293
Practice Address - Street 1:217 WEST CENTRAL AVENUE
Practice Address - Street 2:SUITE G
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-2830
Practice Address - Country:US
Practice Address - Phone:805-735-4292
Practice Address - Fax:805-735-4293
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2015-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69286207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB207338OtherMEDICARE ID
CAY19825Medicare UPIN