Provider Demographics
NPI:1407928369
Name:WIETHOLTER, DALE RAY (MD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:RAY
Last Name:WIETHOLTER
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 1:8782 ESTATE DR
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-6592
Mailing Address - Country:US
Mailing Address - Phone:561-791-0376
Mailing Address - Fax:
Practice Address - Street 1:2007 PALM BEACH LAKES BLVD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-6501
Practice Address - Country:US
Practice Address - Phone:561-420-8555
Practice Address - Fax:888-442-6078
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME25941207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD27924Medicare UPIN