Provider Demographics
NPI:1114940046
Name:DELAND, MARY MAITLAND (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MAITLAND
Last Name:DELAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 ALICE DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-5083
Mailing Address - Country:US
Mailing Address - Phone:337-989-0812
Mailing Address - Fax:337-284-3799
Practice Address - Street 1:1507 ALICE DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-5083
Practice Address - Country:US
Practice Address - Phone:337-989-0812
Practice Address - Fax:337-284-3799
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05746R2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1319236Medicaid
LAP00475837OtherMEDICARE RR
LA5DX68OtherONCOLOGICS LLC GROUP PTAN EFFECTIVE 05/19/2012
LA5L616DX68OtherM. MAITLAND DELAND MEDICARE PTAN EFFECTIVE 05/19/2012
LA5L616DB49Medicare PIN
LAP00475837OtherMEDICARE RR
LA5L616DX68OtherM. MAITLAND DELAND MEDICARE PTAN EFFECTIVE 05/19/2012