Healthcare Provider Details

I. General information

NPI: 1023018462
Provider Name (Legal Business Name): DALE W SPONAUGLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 08/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 OHIO ST
MEDINA NY
14103-1063
US

IV. Provider business mailing address

275 NORTHPOINTE PKWY STE 50
AMHERST NY
14228-1895
US

V. Phone/Fax

Practice location:
  • Phone: 585-798-8054
  • Fax: 585-798-8150
Mailing address:
  • Phone: 716-692-2160
  • Fax: 716-692-4342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number164356
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: