Provider Demographics
NPI:1740226000
Name:ELLESON, DALE ALLAN (DO)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:ALLAN
Last Name:ELLESON
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 1:2557 MOWRY AVE
Mailing Address - Street 2:#30
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538
Mailing Address - Country:US
Mailing Address - Phone:510-797-9999
Mailing Address - Fax:510-797-9783
Practice Address - Street 1:2557 MOWRY AVE
Practice Address - Street 2:#30
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538
Practice Address - Country:US
Practice Address - Phone:510-797-9999
Practice Address - Fax:510-797-9783
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4511207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX45110Medicaid
CA020A45110Medicare ID - Type Unspecified
CA00AX45110Medicaid