Provider Demographics
NPI:1134518053
Name:DELAINE LLC
Entity Type:Organization
Organization Name:DELAINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:VAN PUTTEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-464-7546
Mailing Address - Street 1:1620 COUNTRY CLUB RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2251
Mailing Address - Country:US
Mailing Address - Phone:219-464-7546
Mailing Address - Fax:866-467-3763
Practice Address - Street 1:1620 COUNTRY CLUB RD
Practice Address - Street 2:SUITE C
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2251
Practice Address - Country:US
Practice Address - Phone:219-464-7546
Practice Address - Fax:866-467-3763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-15
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039408A207W00000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201275700A, B, CMedicaid
IN000000917194OtherANTHEM
IN000000917194OtherANTHEM