Provider Demographics
NPI:1366440323
Name:DELOLLIS, MICHAEL V (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:V
Last Name:DELOLLIS
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 1:1220 NW KINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-2521
Mailing Address - Country:US
Mailing Address - Phone:541-321-8552
Mailing Address - Fax:
Practice Address - Street 1:1220 NW KINGS BLVD
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-2521
Practice Address - Country:US
Practice Address - Phone:541-321-8552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG597262084P0800X
ORMD117482084P0800X
ORMD1750032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500708139Medicaid
C04345Medicare UPIN
ORR188789Medicare PIN
CA00G597261Medicare PIN
CAC04345Medicare UPIN