1407805856 NPI number — MICHAEL R DEPIETRO MD

Table of content: MICHAEL R DEPIETRO MD (NPI 1407805856)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407805856 NPI number — MICHAEL R DEPIETRO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEPIETRO
Provider First Name:
MICHAEL
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407805856
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4745 OGLETOWN STANTON RD
Provider Second Line Business Mailing Address:
MAP 1, SUITE 220
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19713-2067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-368-5515
Provider Business Mailing Address Fax Number:
302-366-1240

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4745 OGLETOWN STANTON RD
Provider Second Line Business Practice Location Address:
MAP 1, SUITE 220
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19713-2067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-368-5515
Provider Business Practice Location Address Fax Number:
302-366-1240
Provider Enumeration Date:
05/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  C10005688 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0295282000 . This is a "AMERIHEALTH/KEYSTONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 60959401 . This is a "CARE FIRST BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 0000974301 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1255450004 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 550894 . This is a "INDEPENDENCE BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 58079 . This is a "COVENTRY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 289288 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4397310 . This is a "AETNA/USHC" identifier . This identifiers is of the category "OTHER".




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