Provider Demographics
NPI:1780725408
Name:PROKUPEK, DALE ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:ALAN
Last Name:PROKUPEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8641 WILSHIRE BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-2919
Mailing Address - Country:US
Mailing Address - Phone:310-360-6807
Mailing Address - Fax:310-360-6683
Practice Address - Street 1:8641 WILSHIRE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2900
Practice Address - Country:US
Practice Address - Phone:310-360-6807
Practice Address - Fax:310-360-6683
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG71035207RG0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1548569197OtherGROUP NPI
CAG71035AMedicare ID - Type Unspecified
CA1548569197OtherGROUP NPI