Provider Demographics
NPI:1518003243
Name:SOVAK, DALE (DPM, CPED)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:
Last Name:SOVAK
Suffix:
Gender:M
Credentials:DPM, CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4576 E 2ND ST
Mailing Address - Street 2:H
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-1046
Mailing Address - Country:US
Mailing Address - Phone:707-751-1630
Mailing Address - Fax:925-226-3184
Practice Address - Street 1:4576 E 2ND ST
Practice Address - Street 2:H
Practice Address - City:BENICIA
Practice Address - State:CA
Practice Address - Zip Code:94510-1046
Practice Address - Country:US
Practice Address - Phone:707-751-1630
Practice Address - Fax:925-226-3184
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4144213ES0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU71138Medicare UPIN