Provider Demographics
NPI:1053442228
Name:DELACEY, JONATHAN H (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:H
Last Name:DELACEY
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:PO BOX 394
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:NE
Mailing Address - Zip Code:68028-0394
Mailing Address - Country:US
Mailing Address - Phone:877-406-2916
Mailing Address - Fax:719-591-2745
Practice Address - Street 1:1010 THREE SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-8296
Practice Address - Country:US
Practice Address - Phone:970-764-2286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO393242085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO34106839Medicaid
CO84115593607OtherROCKY MOUNTAIN HEALTH
CORAB6508OtherBLUE CROSS BLUE SHIELD
UTT0334Medicaid
CA5302835Medicaid
69185OtherPRESBYTERIAN
AZ825705Medicaid
84115593607OtherPACIFICARE
NMF2427Medicaid
84115593607OtherPACIFICARE
H40528Medicare UPIN
CA5302835Medicaid