MEDICARE: MR. DALE EDWIN WOLFORD DO

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	207V00000X	Obstetrics & Gynecology Physician	H0063736	MD
2	207V00000X	Obstetrics & Gynecology Physician	OS4624	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1966	OTHER	WV	WEST VA MEDICAL LICENSE

General Provider Information

NPI Number	:	1417902164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DALE EDWIN WOLFORD DO

Provider Business Mailing Address
First Line	:	700 8TH AVE W
Second Line	:	STE 101
City	:	PALMETTO
State	:	FL
Zip	:	34221-4737
Country	:	US
Telephone Number	:	941-776-4008
Fax Number	:	941-845-4963

Provider Business Practice Location Address
First Line	:	1110 E GIBSON ST
Second Line	:
City	:	ARCADIA
State	:	FL
Zip	:	34266-5011
Country	:	US
Telephone Number	:	863-494-1918
Fax Number	:	863-993-2116

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

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	03/24/2017

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