Basic Information
| Provider Information | |||||||||
| NPI: | 1053442228 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DELACEY | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 394 | ||||||||
| Address2: | |||||||||
| City: | GRETNA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680280394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774062916 | ||||||||
| FaxNumber: | 7195912745 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 THREE SPRINGS BLVD | ||||||||
| Address2: | |||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813018296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707642286 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 07/07/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 39324 | CO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 34106839 | 05 | CO | MEDICAID | 84115593607 | 01 | CO | ROCKY MOUNTAIN HEALTH | OTHER | RAB6508 | 01 | CO | BLUE CROSS BLUE SHIELD | OTHER | T0334 | 05 | UT | MEDICAID | 5302835 | 05 | CA | MEDICAID | 69185 | 01 | PRESBYTERIAN | OTHER | 825705 | 05 | AZ | MEDICAID | 84115593607 | 01 | PACIFICARE | OTHER | F2427 | 05 | NM | MEDICAID |