1679666911 NPI number — DR. ROBERT ANDREW DALE D.P.M.

Table of content: DR. ROBERT ANDREW DALE D.P.M. (NPI 1679666911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679666911 NPI number — DR. ROBERT ANDREW DALE D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DALE
Provider First Name:
ROBERT
Provider Middle Name:
ANDREW
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679666911
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 DAVISSON RUN RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
CLARKSBURG
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26301-9307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-623-6728
Provider Business Mailing Address Fax Number:
304-623-2638

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 DAVISSON RUN RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CLARKSBURG
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26301-9307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-623-6728
Provider Business Practice Location Address Fax Number:
304-623-2638
Provider Enumeration Date:
09/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  10395 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213E00000X , with the licence number: N006127 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3810008964 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 311573127 . This is a "GROUP TAX ID #" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: P00400794 . This is a "UMWA (FUNDS)" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 10395 . This is a "WV STATE PODIATRY LICENSE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: WV10395 . This is a "HEALTH PLAN" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: N006127 . This is a "NEW YORK PODIATRY LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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