Provider Demographics
NPI:1922032077
Name:WESTROM, DALE RAYMOND (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:RAYMOND
Last Name:WESTROM
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 SONOMA AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4813
Mailing Address - Country:US
Mailing Address - Phone:707-579-4239
Mailing Address - Fax:
Practice Address - Street 1:990 SONOMA AVE STE 2
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4813
Practice Address - Country:US
Practice Address - Phone:707-579-4239
Practice Address - Fax:707-579-0459
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46342207N00000X, 207NS0135X
CAG46242207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G46342Medicaid
CA00G46342Medicaid
CA00G463420Medicare ID - Type Unspecified