Provider Demographics
NPI:1811993744
Name:DALE, LEONARD E II (MD)
Entity type:Individual
Prefix:
First Name:LEONARD
Middle Name:E
Last Name:DALE
Suffix:II
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:PO BOX 21
Mailing Address - Street 2:
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-0021
Mailing Address - Country:US
Mailing Address - Phone:570-723-0163
Mailing Address - Fax:570-723-0188
Practice Address - Street 1:32-36 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1840
Practice Address - Country:US
Practice Address - Phone:570-723-0163
Practice Address - Fax:570-723-0188
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD013080E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009512600001Medicaid
PA108499Medicare PIN
C30335Medicare UPIN