Basic Information
| Provider Information | |||||||||
| NPI: | 1225106602 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EKSTRUM | ||||||||
| FirstName: | DALE | ||||||||
| MiddleName: | ETHAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 WEST BUNNY AVENUE | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934582805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057354292 | ||||||||
| FaxNumber: | 8057354293 | ||||||||
| Practice Location | |||||||||
| Address1: | 217 WEST CENTRAL AVENUE | ||||||||
| Address2: | SUITE G | ||||||||
| City: | LOMPOC | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934362830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057354292 | ||||||||
| FaxNumber: | 8057354293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 12/26/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G69286 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CB207338 | 01 | CA | MEDICARE ID | OTHER |