Provider Demographics
NPI:1528128444
Name:NYSTROM, DALE (MD)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:
Last Name:NYSTROM
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 1:645 S MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX CENTER
Mailing Address - State:IA
Mailing Address - Zip Code:51250-1347
Mailing Address - Country:US
Mailing Address - Phone:712-722-2609
Mailing Address - Fax:712-722-8392
Practice Address - Street 1:645 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:SIOUX CENTER
Practice Address - State:IA
Practice Address - Zip Code:51250-1347
Practice Address - Country:US
Practice Address - Phone:712-722-2609
Practice Address - Fax:712-722-8392
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21738207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAA01482Medicare UPIN