Provider Demographics
NPI:1194845388
Name:DELADISMA, ADELINE MAE (MD)
Entity Type:Individual
Prefix:
First Name:ADELINE
Middle Name:MAE
Last Name:DELADISMA
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 1:11141 PARKVIEW PLAZA DR
Mailing Address - Street 2:SUITE 305
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1713
Mailing Address - Country:US
Mailing Address - Phone:260-484-9611
Mailing Address - Fax:260-484-1004
Practice Address - Street 1:11141 PARKVIEW PLAZA DR
Practice Address - Street 2:SUITE 305
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1713
Practice Address - Country:US
Practice Address - Phone:260-484-9611
Practice Address - Fax:260-484-1004
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00498208600000X
MDD72711208600000X
IN01071770A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD97509402OtherBCBS
MD97509403OtherBCBS
MD97509401OtherBCBS
DCV8080011OtherBCBS
DCV8380011OtherBCBS
DCV8740011OtherBCBS
MD045199100Medicaid
DCV8380011OtherBCBS
MD225800Y5ZMedicare PIN
DCV8740011OtherBCBS