Provider Demographics
NPI:1407568710
Name:DELLERBA, NICHOLAS
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:
Last Name:DELLERBA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2274 LOCKAMY CT
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-1565
Mailing Address - Country:US
Mailing Address - Phone:614-202-9202
Mailing Address - Fax:
Practice Address - Street 1:2274 LOCKAMY CT
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-1565
Practice Address - Country:US
Practice Address - Phone:614-202-9202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2573648Medicaid