Provider Demographics
NPI:1952394041
Name:BREWER, DALE J (DO)
Entity type:Individual
Prefix:MR
First Name:DALE
Middle Name:J
Last Name:BREWER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:6420 THE CEDARS CT
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:MO
Mailing Address - Zip Code:63016-2222
Mailing Address - Country:US
Mailing Address - Phone:636-274-2700
Mailing Address - Fax:636-274-4660
Practice Address - Street 1:6420 THE CEDARS CT
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:MO
Practice Address - Zip Code:63016-2222
Practice Address - Country:US
Practice Address - Phone:636-274-2700
Practice Address - Fax:636-274-4660
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8F65207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO242286706Medicaid
MOD41541Medicare UPIN
MO242286706Medicaid