1598904740 NPI number — DR. MIGUEL B DELMAZO MD

Table of content: DR. MIGUEL B DELMAZO MD (NPI 1598904740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598904740 NPI number — DR. MIGUEL B DELMAZO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DELMAZO
Provider First Name:
MIGUEL
Provider Middle Name:
B
Provider Name Prefix Text:
DR.
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:
1598904740
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5403 OAK CREST LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUFORD
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30518-9029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-722-9753
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3215 MCCLURE BRIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30096
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-312-6200
Provider Business Practice Location Address Fax Number:
678-312-6226
Provider Enumeration Date:
02/11/2009

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: 208600000X , with the licence number:  065651 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003114073F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003114073L , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9738749 . This is a "AETNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 52515750 . This is a "BCBS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 003114073N , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1489990 . This is a "COVENTRY" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 003114073H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003114073K , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02378992 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 003114073I , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003114073M , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003114073G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1022567 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 9672923 . This is a "CIGNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 003114073J , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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