Basic Information
| Provider Information | |||||||||
| NPI: | 1659323756 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WULF | ||||||||
| FirstName: | DALE | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 915 13TH AVE N | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527325067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5632432511 | ||||||||
| FaxNumber: | 5632430817 | ||||||||
| Practice Location | |||||||||
| Address1: | 915 13TH AVE N | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527325067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5632432511 | ||||||||
| FaxNumber: | 5632430817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 03/15/2013 | ||||||||
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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 | 18136 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0180369123 | 05 | IL | MEDICAID | 27174 | 01 | IA | IOWA HEALTH SOLUTIONS | OTHER | 018394 | 01 | HEALTH ALLIANCE | OTHER | 20979 | 01 | MIDLANDS CHOICE | OTHER | 0085191 | 05 | IA | MEDICAID | IA0113 | 01 | JOHN DEERE HEALTH | OTHER | 20823 | 01 | IA | WELLMARK BC/BS | OTHER |