Provider Demographics
NPI:1568463925
Name:DALE, DAVID W (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:W
Last Name:DALE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 817
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63702-0817
Mailing Address - Country:US
Mailing Address - Phone:573-335-4715
Mailing Address - Fax:573-334-2303
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:417-967-2630
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3C32207Q00000X
261QR1300X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO242088722Medicaid
MO207623109Medicaid
MO598235703Medicaid
MO001013745OtherMEDICARE PART B
MO503362600Medicaid
MO593362601Medicaid
MO001013745OtherMEDICARE PART B
MO207623109Medicaid
MO263812Medicare Oscar/Certification