Provider Demographics
NPI:1811218332
Name:DALE, ELIZABETH A (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:DALE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PRESIDENTIAL BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1108
Mailing Address - Country:US
Mailing Address - Phone:484-434-2700
Mailing Address - Fax:484-434-2793
Practice Address - Street 1:100 PRESIDENTIAL BLVD STE 200
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1108
Practice Address - Country:US
Practice Address - Phone:484-434-2700
Practice Address - Fax:484-434-2793
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09688200207W00000X, 207WX0009X
FLME119151207W00000X
PAMD454366207WX0009X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0469068Medicaid
NJ0469068Medicaid
NJ420507C9YMedicare PIN