Provider Demographics
NPI:1760481014
Name:DALE, JONATHAN B (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:B
Last Name:DALE
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 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:400 FAIRVIEW HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-9308
Practice Address - Country:US
Practice Address - Phone:304-872-2891
Practice Address - Fax:304-872-6854
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23453207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810014181Medicaid
WVDA7395861OtherMEDICARE PTAN