Provider Demographics
NPI:1316056369
Name:DE LA SIERRA, DAVID ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ANTHONY
Last Name:DE LA SIERRA
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:P.O. BOX 28170
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31221-8170
Mailing Address - Country:US
Mailing Address - Phone:478-254-5943
Mailing Address - Fax:478-254-6093
Practice Address - Street 1:528 S 8TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4212
Practice Address - Country:US
Practice Address - Phone:770-467-1224
Practice Address - Fax:770-467-1225
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056820207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA382655211AMedicaid
GAP00734398OtherMEDICARE RAILROAD
GA511I080598Medicare PIN
GAP00734398OtherMEDICARE RAILROAD
GAI44371Medicare UPIN
I44371Medicare UPIN