Provider Demographics
NPI:1790837938
Name:DELLACQUA, DALE (MD)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:
Last Name:DELLACQUA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 S WALKER ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2123
Mailing Address - Country:US
Mailing Address - Phone:812-333-4000
Mailing Address - Fax:812-333-0611
Practice Address - Street 1:639 S WALKER ST
Practice Address - Street 2:SUITE E
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2123
Practice Address - Country:US
Practice Address - Phone:812-333-4000
Practice Address - Fax:812-333-0611
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01050231A207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
H21285Medicare UPIN
545620GMedicare ID - Type Unspecified