Provider Demographics
NPI:1114034386
Name:DELORIA, ESCOLASTICO AUSEJO JR (MD)
Entity Type:Individual
Prefix:
First Name:ESCOLASTICO
Middle Name:AUSEJO
Last Name:DELORIA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:E
Other - Middle Name:A
Other - Last Name:DELORIA
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1700 E 38TH ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46953-4568
Mailing Address - Country:US
Mailing Address - Phone:765-674-6965
Mailing Address - Fax:
Practice Address - Street 1:1700 E 38TH ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-4568
Practice Address - Country:US
Practice Address - Phone:765-674-6965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME332132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry