Provider Demographics
NPI:1528094695
Name:DELVECCHIO, JEFFREY S (PA)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:S
Last Name:DELVECCHIO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:3050 E RIVER BLUFF BLVD
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-8807
Practice Address - Country:US
Practice Address - Phone:417-820-5610
Practice Address - Fax:417-820-5588
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114082363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO970010692OtherRAILROAD MEDICARE
MO431560263OtherTRICARE
MO431560263OtherTRICARE
MO000085185Medicare PIN
MO970010692OtherRAILROAD MEDICARE