MEDICARE: DANIEL L DALE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	30832	WI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	5966510002	OTHER	WI	MEDICARE NCS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	161633405011	OTHER		BCBS

General Provider Information

NPI Number	:	1326042730
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL L DALE M.D.

Provider Business Mailing Address
First Line	:	1525 PARK PLACE
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-1979
Country	:	US
Telephone Number	:	920-965-1234
Fax Number	:	920-965-1232

Provider Business Practice Location Address
First Line	:	1525 PARK PLACE
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-1979
Country	:	US
Telephone Number	:	920-965-1234
Fax Number	:	920-965-1232

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	01/26/2010

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