1770763310 NPI number — ANTONIO DELARA M.D., P.C.

Table of content: (NPI 1770763310)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770763310 NPI number — ANTONIO DELARA M.D., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANTONIO DELARA M.D., P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1770763310
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/13/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1611 MONROE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEARBORN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48124-2912
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-278-7100
Provider Business Mailing Address Fax Number:
313-562-2216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1611 MONROE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEARBORN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48124-2912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-278-7100
Provider Business Practice Location Address Fax Number:
313-562-2216
Provider Enumeration Date:
11/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DELARA
Authorized Official First Name:
ANTONIO
Authorized Official Middle Name:
FERNANDEZ
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
313-562-3832

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  AD048423 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4596660 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: P47900 . This is a "BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1108225362 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5605727 . This is a "CIGNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: AD048423 . This is a "STATE LICENCE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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