Healthcare Provider Details

I. General information

NPI: 1811993744
Provider Name (Legal Business Name): LEONARD E. DALE II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 11/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32-36 CENTRAL AVE
WELLSBORO PA
16901-1840
US

IV. Provider business mailing address

PO BOX 21
WELLSBORO PA
16901-0021
US

V. Phone/Fax

Practice location:
  • Phone: 570-723-0163
  • Fax: 570-723-0188
Mailing address:
  • Phone: 570-723-0163
  • Fax: 570-723-0188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD013080E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: