Provider Demographics
NPI:1710205364
Name:LOOMIS, S. DALE (MD)
Entity type:Individual
Prefix:DR
First Name:S.
Middle Name:DALE
Last Name:LOOMIS
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 1:229 CAMPBELL CT
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-2076
Mailing Address - Country:US
Mailing Address - Phone:630-232-2331
Mailing Address - Fax:630-845-9145
Practice Address - Street 1:229 CAMPBELL CT
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2076
Practice Address - Country:US
Practice Address - Phone:630-232-2331
Practice Address - Fax:630-845-9145
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360382472084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry