Provider Demographics
NPI:1316133358
Name:DALE EKSTRUM MD INC
Entity type:Organization
Organization Name:DALE EKSTRUM MD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:ETHAN
Authorized Official - Last Name:EKSTRUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-735-4292
Mailing Address - Street 1:217 W CENTRAL AVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-2830
Mailing Address - Country:US
Mailing Address - Phone:805-735-4292
Mailing Address - Fax:805-735-4293
Practice Address - Street 1:217 W CENTRAL AVE
Practice Address - Street 2:SUITE G
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-2830
Practice Address - Country:US
Practice Address - Phone:805-735-4292
Practice Address - Fax:805-735-4293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69286207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAY19825Medicare UPIN
CAW18062Medicare PIN