Basic Information
| Provider Information | |||||||||
| NPI: | 1528094695 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DELVECCHIO | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2580 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658012580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178294620 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3050 E RIVER BLUFF BLVD | ||||||||
| Address2: | |||||||||
| City: | OZARK | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657218807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178205610 | ||||||||
| FaxNumber: | 4178205588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 11/21/2013 | ||||||||
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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 | 363A00000X | 114082 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 970010692 | 01 | MO | RAILROAD MEDICARE | OTHER | 431560263 | 01 | MO | TRICARE | OTHER |