Provider Demographics
NPI:1780839886
Name:DALE WARREN SPONAUGLE, MD, PC
Entity Type:Organization
Organization Name:DALE WARREN SPONAUGLE, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:W
Authorized Official - Last Name:SPONAUGLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-798-8054
Mailing Address - Street 1:908 NIAGARA FALLS BLVD
Mailing Address - Street 2:STE 208
Mailing Address - City:N TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-2019
Mailing Address - Country:US
Mailing Address - Phone:716-692-3302
Mailing Address - Fax:716-692-4342
Practice Address - Street 1:200 OHIO ST
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:NY
Practice Address - Zip Code:14103-1063
Practice Address - Country:US
Practice Address - Phone:585-798-8054
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1643562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01257134Medicaid
NY000525331009OtherBLUE CROSS OF WNY
NY5690902OtherIHA
NY00020548502OtherUNIVERA
NY9600955OtherGHI - PPO
NYP010164356OtherBLUE CHOICE
NY040426004344OtherFIDELIS
NY000525331009OtherBLUE CROSS OF WNY