Provider Demographics
NPI:1548569197
Name:DALE PROKUPEK MD INC
Entity Type:Organization
Organization Name:DALE PROKUPEK MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PROKUPEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-360-6807
Mailing Address - Street 1:1710 N FAIRFAX AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-2136
Mailing Address - Country:US
Mailing Address - Phone:310-360-6807
Mailing Address - Fax:310-360-6683
Practice Address - Street 1:8641 WILSHIRE BLVD
Practice Address - Street 2:100
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2900
Practice Address - Country:US
Practice Address - Phone:310-360-6807
Practice Address - Fax:310-360-6683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG71035207RG0100X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG71035AOtherMEDICARE PTAN