Healthcare Provider Details

I. General information

NPI: 1548569197
Provider Name (Legal Business Name): DALE PROKUPEK MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2011
Last Update Date: 03/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8641 WILSHIRE BLVD 100
BEVERLY HILLS CA
90211-2900
US

IV. Provider business mailing address

1710 N FAIRFAX AVE
LOS ANGELES CA
90046-2136
US

V. Phone/Fax

Practice location:
  • Phone: 310-360-6807
  • Fax: 310-360-6683
Mailing address:
  • Phone: 310-360-6807
  • Fax: 310-360-6683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberG71035
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG71035
License Number StateCA

VIII. Authorized Official

Name: DR. DALE A PROKUPEK
Title or Position: OWNER
Credential: M.D.
Phone: 310-360-6807