Healthcare Provider Details

I. General information

NPI: 1164490199
Provider Name (Legal Business Name): DALE INTIHAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 02/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 PALM COAST PKWY NE
PALM COAST FL
32137-3886
US

IV. Provider business mailing address

PO BOX 9671
DAYTONA BEACH FL
32120
US

V. Phone/Fax

Practice location:
  • Phone: 386-445-7073
  • Fax: 386-447-7092
Mailing address:
  • Phone: 386-676-7130
  • Fax: 386-676-7125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME89456
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: