Basic Information
Provider Information | |||||||||
NPI: | 1679622336 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DELK | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 35380 | ||||||||
Address2: |   | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891335380 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7025793296 | ||||||||
FaxNumber: | 7028008229 | ||||||||
Practice Location | |||||||||
Address1: | 220 N SYKES CREEK PKWY | ||||||||
Address2: | SUITE 1 | ||||||||
City: | MERRITT ISLAND | ||||||||
State: | FL | ||||||||
PostalCode: | 329533490 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3217843700 | ||||||||
FaxNumber: | 8666652702 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/10/2007 | ||||||||
LastUpdateDate: | 12/21/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME0065273 | FL | N |   | Other Service Providers | Specialist |   | 207L00000X | ME65273 | FL | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207L00000X | 16231 | NV | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
No ID Information.