Basic Information
| Provider Information | |||||||||
| NPI: | 1750815080 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE LANNOY | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 N TENAYA WAY | ||||||||
| Address2: | GRADUATE MEDICAL EDUCATION | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891280431 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3100 N TENAYA WAY | ||||||||
| Address2: | GRADUATE MEDICAL EDUCATION | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891280431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029625000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2017 | ||||||||
| LastUpdateDate: | 06/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | DR.0065143 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 029147 | 01 | CO | KAISER COMMERCIAL NUMBER | OTHER |