Provider Demographics
NPI:1033348057
Name:MUSIELAK, DELENE PRENITA (MD)
Entity Type:Individual
Prefix:DR
First Name:DELENE
Middle Name:PRENITA
Last Name:MUSIELAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DELENE
Other - Middle Name:PRENITA
Other - Last Name:ETWARU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8857B LADUE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124-2058
Mailing Address - Country:US
Mailing Address - Phone:146-823-6263
Mailing Address - Fax:314-590-5933
Practice Address - Street 1:8857B LADUE RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63124-2058
Practice Address - Country:US
Practice Address - Phone:314-682-3626
Practice Address - Fax:314-590-5954
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-12
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY46271207R00000X, 208000000X
MO2019012317208000000X, 207R00000X, 208000000X
GA073333208000000X
MO2009018414208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1033348057OtherBCBS-GA
GA003159470AMedicaid
KYP01194331Medicare PIN
KYK085620Medicare PIN