Provider Demographics
NPI:1528264801
Name:DELISIO, MARIO A JR (SA)
Entity type:Individual
Prefix:MR
First Name:MARIO
Middle Name:A
Last Name:DELISIO
Suffix:JR
Gender:M
Credentials:SA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5288 STRAWBERRY LN
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-4373
Mailing Address - Country:US
Mailing Address - Phone:440-942-3319
Mailing Address - Fax:440-460-2825
Practice Address - Street 1:6770 MAYFIELD RD
Practice Address - Street 2:SUITE # 300
Practice Address - City:MAYFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44124-2299
Practice Address - Country:US
Practice Address - Phone:440-460-2822
Practice Address - Fax:440-460-2825
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNONE REQUIRED156FX1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1101XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic Assistant