Individual
JONATHAN B DALE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
400 FAIRVIEW HEIGHTS RD, SUMMERSVILLE, WV 26651-9308
(304) 872-2891
(304) 872-6854
Mailing address
200 CORPORATE BLVD, LAFAYETTE, LA 70508-3870
(800) 893-9698
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
23453
WV
207Q00000X
Family Medicine Physician
23453
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3810014181
—
WV
01
—
DA7395861
MEDICARE PTAN
WV
Enumeration date
07/19/2005
Last updated
04/21/2022
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