Provider Demographics
NPI:1194721100
Name:DELPORT, BRENDON (DO)
Entity type:Individual
Prefix:DR
First Name:BRENDON
Middle Name:
Last Name:DELPORT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 N NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-4306
Mailing Address - Country:US
Mailing Address - Phone:417-837-4003
Mailing Address - Fax:417-875-4782
Practice Address - Street 1:2828 N NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-4306
Practice Address - Country:US
Practice Address - Phone:417-837-4003
Practice Address - Fax:417-875-4782
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004008249207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1194721100Medicaid
P00261949OtherRR MEDICARE
MO209165604Medicaid
MO209165604Medicaid
927275115Medicare ID - Type Unspecified
MO1194721100Medicaid