1558591990 NPI number — DR. DAN CONSTANTINE DELIGIANIS M.D.

Table of content: DR. DAN CONSTANTINE DELIGIANIS M.D. (NPI 1558591990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558591990 NPI number — DR. DAN CONSTANTINE DELIGIANIS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DELIGIANIS
Provider First Name:
DAN
Provider Middle Name:
CONSTANTINE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DELIGIANIS
Provider Other First Name:
DAN
Provider Other Middle Name:
C.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1558591990
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
616 HURON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT HURON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48060-5011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-985-6933
Provider Business Mailing Address Fax Number:
810-987-4572

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4170 FAIRWAY DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT GRATIOT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48059-3702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-385-8752
Provider Business Practice Location Address Fax Number:
810-987-4572
Provider Enumeration Date:
07/20/2009

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: 207W00000X , with the licence number:  4301042936 , 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)





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