Provider Demographics
NPI:1417769894
Name:DELTA CORPS DIAGNOSTICS LLC
Entity type:Organization
Organization Name:DELTA CORPS DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTAW
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:734-389-5832
Mailing Address - Street 1:495 GRAND BLVD STE 206
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-1897
Mailing Address - Country:US
Mailing Address - Phone:734-389-5832
Mailing Address - Fax:
Practice Address - Street 1:495 GRAND BLVD STE 206
Practice Address - Street 2:
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-1897
Practice Address - Country:US
Practice Address - Phone:734-389-5832
Practice Address - Fax:813-489-9562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-23
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty