Provider Demographics
NPI:1215948351
Name:MOCK, DALE L (MD)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:L
Last Name:MOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10798 W. OVERLAND RD
Mailing Address - Street 2:BOISE FAMILY MEDICINE CENTER
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1329
Mailing Address - Country:US
Mailing Address - Phone:208-377-3368
Mailing Address - Fax:208-322-4691
Practice Address - Street 1:10798 W. OVERLAND RD
Practice Address - Street 2:BOISE FAMILY MEDICINE CENTER
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1329
Practice Address - Country:US
Practice Address - Phone:208-377-3368
Practice Address - Fax:208-322-4691
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3211207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID34611OtherBLUE CROSS
ID000010004262OtherBLUE SHIELD
ID080086509OtherRAILROAD MEDICARE
080086509OtherMEDICARE RAILROAD
ID002643300Medicaid
ID080086509OtherRAILROAD MEDICARE
ID002643300Medicaid
ID000010004262OtherBLUE SHIELD