Provider Demographics
NPI:1841360591
Name:SYVERSON, DALE LOWELL (MD)
Entity type:Individual
Prefix:MR
First Name:DALE
Middle Name:LOWELL
Last Name:SYVERSON
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 1:1825 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130-4518
Mailing Address - Country:US
Mailing Address - Phone:530-252-4115
Mailing Address - Fax:530-252-4117
Practice Address - Street 1:1825 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130
Practice Address - Country:US
Practice Address - Phone:530-252-4115
Practice Address - Fax:530-252-4117
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG87246208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G6872460Medicaid
E16054Medicare UPIN
00G872460Medicare ID - Type Unspecified