Provider Demographics
NPI:1528199494
Name:DAVID W DALE
Entity Type:Organization
Organization Name:DAVID W DALE
Other - Org Name:DALE FAMILY MEDICINE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:DALE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:417-967-3755
Mailing Address - Street 1:1340 S SAM HOUSTON BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MO
Mailing Address - Zip Code:65483-2045
Mailing Address - Country:US
Mailing Address - Phone:417-967-3755
Mailing Address - Fax:417-967-3630
Practice Address - Street 1:1340 S SAM HOUSTON BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MO
Practice Address - Zip Code:65483-2045
Practice Address - Country:US
Practice Address - Phone:417-967-3755
Practice Address - Fax:417-967-3630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO263854Medicare Oscar/Certification
MO263812AMedicare Oscar/Certification