Provider Demographics
NPI:1326042789
Name:WHITAKER, DALE A (MD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:A
Last Name:WHITAKER
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 1:705 WELLS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-2982
Mailing Address - Country:US
Mailing Address - Phone:904-282-6331
Mailing Address - Fax:904-619-1080
Practice Address - Street 1:8262 POINT MEADOWS DR STE 202
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-4700
Practice Address - Country:US
Practice Address - Phone:904-265-4310
Practice Address - Fax:833-578-1807
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME46812207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010025464OtherRAILROAD MEDICARE
FL0428086-00Medicaid
FLD42293Medicare UPIN
FL14107ZMedicare PIN