Provider Demographics
NPI:1427069442
Name:FOUNTAIN, DALE MEIER (DPM)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:MEIER
Last Name:FOUNTAIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5835 VINE ST
Mailing Address - Street 2:PO BOX 5505
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68505-2847
Mailing Address - Country:US
Mailing Address - Phone:402-466-5677
Mailing Address - Fax:402-466-5677
Practice Address - Street 1:5835 VINE ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68505-2847
Practice Address - Country:US
Practice Address - Phone:402-466-5677
Practice Address - Fax:402-466-5677
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE218213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
480013496OtherRRMC
NE470762478Medicaid
NE261709F0Medicare ID - Type Unspecified
NE470762478Medicaid