Provider Demographics
NPI:1437120110
Name:DAGSBORO FAMILY PRACTICE, P.A.
Entity Type:Organization
Organization Name:DAGSBORO FAMILY PRACTICE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PRENTISS
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ADKINS
Authorized Official - Suffix:SR
Authorized Official - Credentials:DO
Authorized Official - Phone:302-732-9593
Mailing Address - Street 1:29475 VINES CREEK RD
Mailing Address - Street 2:
Mailing Address - City:DAGSBORO
Mailing Address - State:DE
Mailing Address - Zip Code:19939-3839
Mailing Address - Country:US
Mailing Address - Phone:302-732-9593
Mailing Address - Fax:302-732-9598
Practice Address - Street 1:29475 VINES CREEK RD
Practice Address - Street 2:
Practice Address - City:DAGSBORO
Practice Address - State:DE
Practice Address - Zip Code:19939-3839
Practice Address - Country:US
Practice Address - Phone:302-732-9593
Practice Address - Fax:302-732-9598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0002872207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000033073Medicaid
DE1000033073Medicaid
DEB66598Medicare UPIN