Provider Demographics
NPI:1902983885
Name:DELISI, JOHN ROBERT (DC)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:DELISI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 NANSEN CT
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10977-3143
Mailing Address - Country:US
Mailing Address - Phone:845-352-0362
Mailing Address - Fax:
Practice Address - Street 1:11 MEDICAL PARK DR
Practice Address - Street 2:SUITE 104
Practice Address - City:POMONA
Practice Address - State:NY
Practice Address - Zip Code:10970-3559
Practice Address - Country:US
Practice Address - Phone:845-354-5180
Practice Address - Fax:845-354-4104
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00173800111N00000X
NYX011091-1111N00000X
CA12151111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJDC908228Medicare ID - Type Unspecified
T04643Medicare UPIN
NYDC908228Medicare ID - Type Unspecified
NYA300018637Medicare UPIN