Provider Demographics
NPI:1194702472
Name:DELIONBACK, LOUIS A (MD)
Entity type:Individual
Prefix:
First Name:LOUIS
Middle Name:A
Last Name:DELIONBACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3046
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-0746
Mailing Address - Country:US
Mailing Address - Phone:775-352-3080
Mailing Address - Fax:
Practice Address - Street 1:5975 S LOS ALTOS PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89436-7699
Practice Address - Country:US
Practice Address - Phone:775-352-3080
Practice Address - Fax:775-327-4121
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3729207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1194702472OtherNPI
11040113OtherCAQH
NVCG383ZMedicare PIN