Provider Demographics
NPI:1467475715
Name:DALE, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:DALE
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 1:260 TOWNSHIP BLVD
Mailing Address - Street 2:STE 20
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-1674
Mailing Address - Country:US
Mailing Address - Phone:315-708-0190
Mailing Address - Fax:315-488-3284
Practice Address - Street 1:260 TOWNSHIP BLVD
Practice Address - Street 2:STE 20
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-1674
Practice Address - Country:US
Practice Address - Phone:315-708-0190
Practice Address - Fax:315-488-3284
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY137998207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00482279Medicaid
NY56032BMedicare PIN
NY34944DMedicare ID - Type Unspecified
NY00482279Medicaid