Healthcare Provider Details

I. General information

NPI: 1568463925
Provider Name (Legal Business Name): DAVID W DALE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 S SAM HOUSTON BLVD
HOUSTON MO
65483-2045
US

IV. Provider business mailing address

PO BOX 817
CAPE GIRARDEAU MO
63702-0817
US

V. Phone/Fax

Practice location:
  • Phone: 417-967-3755
  • Fax: 417-967-2630
Mailing address:
  • Phone: 573-335-4715
  • Fax: 573-334-2303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR3C32
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: