Provider Demographics
NPI:1366468589
Name:DALITZ, DOUGLAS M (CRNA)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:M
Last Name:DALITZ
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416B MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93901-3306
Mailing Address - Country:US
Mailing Address - Phone:831-800-7887
Mailing Address - Fax:831-998-7155
Practice Address - Street 1:23 UPPER RAGSDALE DR STE 100
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-7849
Practice Address - Country:US
Practice Address - Phone:831-375-3577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10367500000X
CA303557163W00000X
MO059417367500000X
NVTCRNA800146367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO915920714Medicaid
CAZZZ06447ZMedicare PIN
155060042Medicare PIN
P00061575Medicare PIN
OTH000Medicare UPIN
NVER025ZMedicare PIN