Provider Demographics
NPI:1760453534
Name:ABBOTT, DALE R (MD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:R
Last Name:ABBOTT
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 1:835 EAST FAIRHAVEN AVENUE
Mailing Address - Street 2:POB 329
Mailing Address - City:BURLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98233-0329
Mailing Address - Country:US
Mailing Address - Phone:360-755-0641
Mailing Address - Fax:360-755-1405
Practice Address - Street 1:835 EAST FAIRHAVEN AVENUE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98233-0329
Practice Address - Country:US
Practice Address - Phone:360-755-0641
Practice Address - Fax:360-755-1405
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA25209MD00025894207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1054188Medicaid
WA001148601Medicare ID - Type Unspecified
WA1054188Medicaid