Provider Demographics
NPI:1679666911
Name:DALE, ROBERT ANDREW (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ANDREW
Last Name:DALE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:600 DAVISSON RUN RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-9307
Mailing Address - Country:US
Mailing Address - Phone:304-623-6728
Mailing Address - Fax:304-623-2638
Practice Address - Street 1:600 DAVISSON RUN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-9307
Practice Address - Country:US
Practice Address - Phone:304-623-6728
Practice Address - Fax:304-623-2638
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10395213E00000X
NYN006127213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810008964Medicaid
WV311573127OtherGROUP TAX ID #
WVP00400794OtherUMWA (FUNDS)
WV10395OtherWV STATE PODIATRY LICENSE
WVWV10395OtherHEALTH PLAN
NYN006127OtherNEW YORK PODIATRY LICENSE
WV311573127OtherGROUP TAX ID #
NYN006127OtherNEW YORK PODIATRY LICENSE