Provider Demographics
NPI:1255316170
Name:BRAITHWAITE, DALE EVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:EVAN
Last Name:BRAITHWAITE
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 1:17601 DE LONG CIR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-4902
Mailing Address - Country:US
Mailing Address - Phone:714-614-1843
Mailing Address - Fax:
Practice Address - Street 1:17601 DE LONG CIR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-4902
Practice Address - Country:US
Practice Address - Phone:714-614-1843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39582207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA92099Medicare UPIN