Provider Demographics
NPI:1104004209
Name:WILLIAM A. DELP,JR. DO,PC
Entity Type:Organization
Organization Name:WILLIAM A. DELP,JR. DO,PC
Other - Org Name:LOGANVILLE FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/OWNER/OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:DELP
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:770-466-8672
Mailing Address - Street 1:4589 LAWRENCEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-7320
Mailing Address - Country:US
Mailing Address - Phone:770-466-8672
Mailing Address - Fax:770-466-2082
Practice Address - Street 1:4589 LAWRENCEVILLE RD
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-7320
Practice Address - Country:US
Practice Address - Phone:770-466-8672
Practice Address - Fax:770-466-2082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017791207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA235941OtherBLUE CROSS BLUE SHEILD
GAGRP692OtherMEDICARE GROUP
GA406081340OtherRAILROAD MEDICARE
GA406081340OtherRAILROAD MEDICARE
GA232804570AMedicare PIN