Provider Demographics
NPI:1275575110
Name:DELISI, MICHAEL DAVID (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:DELISI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 MAIN ST
Mailing Address - Street 2:ST. JOSEPH'S REGIONAL MEDICAL CENTER
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07503-2621
Mailing Address - Country:US
Mailing Address - Phone:973-754-4100
Mailing Address - Fax:
Practice Address - Street 1:1135 BROAD ST
Practice Address - Street 2:ST. JOSEPH'S FAMILY MEDICINE AT CLIFTON
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3346
Practice Address - Country:US
Practice Address - Phone:973-754-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05259000207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4136403Medicaid
NJ1968009Medicaid
E55041Medicare UPIN
NJ1968009Medicaid