Provider Demographics
NPI:1295705234
Name:ECONOMAN, DALE W (DO)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:W
Last Name:ECONOMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 N RIVER DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2765
Mailing Address - Country:US
Mailing Address - Phone:765-573-5999
Mailing Address - Fax:765-662-0312
Practice Address - Street 1:707 N RIVER DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2765
Practice Address - Country:US
Practice Address - Phone:765-573-5999
Practice Address - Fax:765-662-0312
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000601207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100123380Medicaid
IN215750CMedicare ID - Type Unspecified
IN100123380Medicaid