Basic Information
| Provider Information | |||||||||
| NPI: | 1417063991 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DELLARIA | ||||||||
| FirstName: | MARCO | ||||||||
| MiddleName: | FRANK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 660132 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752660132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143666126 | ||||||||
| FaxNumber: | 2143666127 | ||||||||
| Practice Location | |||||||||
| Address1: | 1420 VICEROY DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752352208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143582300 | ||||||||
| FaxNumber: | 2143666127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 01/27/2010 | ||||||||
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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 | 2085R0204X | L4330 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | 00022884 | AL | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | 036-098601 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | 35072763 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | MD058818L | PA | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 147791101 | 05 | TX | MEDICAID |