Provider Demographics
NPI:1033361712
Name:DELLOS, TISHA GAYETTE (DO)
Entity Type:Individual
Prefix:DR
First Name:TISHA
Middle Name:GAYETTE
Last Name:DELLOS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TISHA
Other - Middle Name:GAYETTE
Other - Last Name:FARRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:740-393-9770
Mailing Address - Fax:740-399-3134
Practice Address - Street 1:1330 COSHOCTON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-1440
Practice Address - Country:US
Practice Address - Phone:740-393-9770
Practice Address - Fax:740-399-3134
Is Sole Proprietor?:No
Enumeration Date:2008-10-14
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.008976207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2938558Medicaid