Provider Demographics
NPI:1366499378
Name:DELISSER, LAWTON O (MD)
Entity Type:Individual
Prefix:
First Name:LAWTON
Middle Name:O
Last Name:DELISSER
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:PO BOX 759047
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-9047
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:713 BETHLEHEM PIKE
Practice Address - Street 2:SUITE 200
Practice Address - City:MONTGOMERYVILLE
Practice Address - State:PA
Practice Address - Zip Code:18936-9602
Practice Address - Country:US
Practice Address - Phone:267-695-3944
Practice Address - Fax:267-695-3945
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD070002L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1715982Medicaid
H20768Medicare UPIN
PA1715982Medicaid