Provider Demographics
NPI:1841276052
Name:INGRAM, DALE CLIFFORD (MD)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:CLIFFORD
Last Name:INGRAM
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 1:979 E 3RD ST
Mailing Address - Street 2:STE C-220
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-3314
Mailing Address - Country:US
Mailing Address - Phone:423-267-4585
Mailing Address - Fax:423-265-4098
Practice Address - Street 1:979 E 3RD ST
Practice Address - Street 2:STE C-220
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-3314
Practice Address - Country:US
Practice Address - Phone:423-267-4585
Practice Address - Fax:423-265-4098
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TND45727174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3871652Medicaid
TNAI1759022OtherDEA
TNAI1759022OtherDEA
TN1004130001Medicare NSC
TN3871652Medicaid