1316908866 NPI number — ELVA GRACE DELPORT MKD

Table of content: ELVA GRACE DELPORT MKD (NPI 1316908866)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316908866 NPI number — ELVA GRACE DELPORT MKD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DELPORT
Provider First Name:
ELVA
Provider Middle Name:
GRACE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MKD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PEARSON
Provider Other First Name:
ELVA
Provider Other Middle Name:
GRACE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1316908866
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4735 OGLETOWN-STANTON RD
Provider Second Line Business Mailing Address:
SUITE 2210
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-623-4144
Provider Business Mailing Address Fax Number:
302-623-4147

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4735 OGLETOWN-STANTON RD
Provider Second Line Business Practice Location Address:
SUITE 2210
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-623-4144
Provider Business Practice Location Address Fax Number:
302-623-4147
Provider Enumeration Date:
03/31/2006

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: 208100000X , with the licence number:  C10005721 , 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: 510110596 . This is a "BCBS OF DE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 2207837 . This is a "AETNA" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 0296025000 . This is a "AMERIHEALTH" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 9132 . This is a "COVENTRY" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 2114925 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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