Provider Demographics
NPI:1407947765
Name:DEJONG, ALLAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLAN
Middle Name:R
Last Name:DEJONG
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 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:CHILDRENS ADVOCACY CENTER OF DELAWARE
Practice Address - Street 2:1600 ROCKLAND ROAD
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3607
Practice Address - Country:US
Practice Address - Phone:302-651-4566
Practice Address - Fax:302-651-4945
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10003999208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7612178Medicaid
NY02730963Medicaid
NJ2089301Medicaid
VA6708382Medicaid
MD3731812Medicaid
SCQ03999Medicaid
MD3731812Medicaid
B38956Medicare UPIN