Provider Demographics
NPI:1578579249
Name:BLOCK, DALE W (MD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:W
Last Name:BLOCK
Suffix:
Gender:M
Credentials:MD
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 345
Mailing Address - Street 2:317 W. PONCA ST
Mailing Address - City:LYNCH
Mailing Address - State:NE
Mailing Address - Zip Code:68746
Mailing Address - Country:US
Mailing Address - Phone:402-569-2741
Mailing Address - Fax:402-569-2780
Practice Address - Street 1:317 W. PONCA ST
Practice Address - Street 2:
Practice Address - City:LYNCH
Practice Address - State:NE
Practice Address - Zip Code:68746
Practice Address - Country:US
Practice Address - Phone:402-569-2741
Practice Address - Fax:402-469-2780
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE15140208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470715545Medicaid
096396Medicare ID - Type Unspecified