Provider Demographics
NPI:1114491792
Name:MOUNTAINSTATE INFECTIOUS DISEASE, PLLC
Entity Type:Organization
Organization Name:MOUNTAINSTATE INFECTIOUS DISEASE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DINO
Authorized Official - Middle Name:
Authorized Official - Last Name:DELAPORTAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-641-1822
Mailing Address - Street 1:11 POINT OF VW
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1082
Mailing Address - Country:US
Mailing Address - Phone:304-641-1822
Mailing Address - Fax:304-250-9933
Practice Address - Street 1:215 W MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1888
Practice Address - Country:US
Practice Address - Phone:301-641-1822
Practice Address - Fax:304-250-9933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty