Provider Demographics
NPI:1013006030
Name:DELISSIO, MICHAEL GERRARD (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GERRARD
Last Name:DELISSIO
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 1:1000 CRESCENT GREEN DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518
Mailing Address - Country:US
Mailing Address - Phone:919-816-4948
Mailing Address - Fax:919-233-7685
Practice Address - Street 1:1000 CRESCENT GREEN DR
Practice Address - Street 2:SUITE 102
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518
Practice Address - Country:US
Practice Address - Phone:919-816-4948
Practice Address - Fax:919-233-7685
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31477174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7928291Medicaid
204041AMedicare ID - Type Unspecified
D26895Medicare UPIN