Provider Demographics
NPI:1336285345
Name:STORMOGIPSON, DALE JUSTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:JUSTIN
Last Name:STORMOGIPSON
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 1:1814 LINCOLN WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2540
Mailing Address - Country:US
Mailing Address - Phone:208-667-2531
Mailing Address - Fax:208-765-9385
Practice Address - Street 1:1814 LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2540
Practice Address - Country:US
Practice Address - Phone:208-667-2531
Practice Address - Fax:208-765-9385
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5936207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002694100Medicaid
15180003516OtherNORTH IDAHO CATARACT & LA
ID000010006023OtherREGENCE BLUE SHIELD OF ID
IDDX761OtherBLUE CROSS OF IDAHO
ID000010006023OtherREGENCE BLUE SHIELD OF ID
820448111OtherEIN
ID1125338Medicare PIN