Provider Demographics
NPI:1598015398
Name:DALE R TRAFICANTE MD PA
Entity Type:Organization
Organization Name:DALE R TRAFICANTE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:TRAFICANTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-274-5757
Mailing Address - Street 1:1890 LPGA BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-7138
Mailing Address - Country:US
Mailing Address - Phone:386-274-5757
Mailing Address - Fax:386-274-1992
Practice Address - Street 1:1890 LPGA BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-7138
Practice Address - Country:US
Practice Address - Phone:386-274-5757
Practice Address - Fax:386-274-1992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75370208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGN883AMedicare PIN