Provider Demographics
NPI:1164272571
Name:DEFELICE, MARIO ANDRES (RDMS)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:ANDRES
Last Name:DEFELICE
Suffix:
Gender:M
Credentials:RDMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4907 THEATER DR
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-8541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4907 THEATER DR
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-8541
Practice Address - Country:US
Practice Address - Phone:812-773-3227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2143672085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound