Provider Demographics
NPI:1265407746
Name:DALE-WALEK, DEBRA L (MD)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:L
Last Name:DALE-WALEK
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:PO BOX 65377
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28265-0377
Mailing Address - Country:US
Mailing Address - Phone:800-377-8721
Mailing Address - Fax:304-523-2241
Practice Address - Street 1:200 HIGH SERVICE AVE
Practice Address - Street 2:
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5113
Practice Address - Country:US
Practice Address - Phone:401-456-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-20
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD07335207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI27417-3OtherBLUECROSS BLUESHIELD
P00167240OtherRAILROAD
RI401267OtherBLUE CHIP
RI7002303Medicaid
F15544Medicare UPIN
RI401267OtherBLUE CHIP