Provider Demographics
NPI:1427682962
Name:DELVALLE, IAN MICHAEL (DO)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:MICHAEL
Last Name:DELVALLE
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 1:88TH MEDICAL GROUP
Mailing Address - Street 2:4881 SUGAR MAPLE DR
Mailing Address - City:WPAFB
Mailing Address - State:OH
Mailing Address - Zip Code:45433
Mailing Address - Country:US
Mailing Address - Phone:937-257-0837
Mailing Address - Fax:
Practice Address - Street 1:88TH MEDICAL GROUP
Practice Address - Street 2:4881 SUGAR MAPLE DR.
Practice Address - City:WPAFB
Practice Address - State:OH
Practice Address - Zip Code:45305
Practice Address - Country:US
Practice Address - Phone:937-257-0837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.017193207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine