Provider Demographics
NPI:1013003904
Name:DELAVAN, GEORGE W (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:W
Last Name:DELAVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2691 COMANCHE CIR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-2807
Mailing Address - Country:US
Mailing Address - Phone:801-581-1258
Mailing Address - Fax:
Practice Address - Street 1:44 N MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-584-8239
Practice Address - Fax:801-584-8588
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT160530-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT999000021002Medicaid
UT876000545OtherSTATE OF UTAH DEPT. OF HEALTH