Provider Demographics
NPI:1417984840
Name:DELLIS, MICHAEL DEAN (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DEAN
Last Name:DELLIS
Suffix:
Gender:M
Credentials:OD
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 779
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:76645-0779
Mailing Address - Country:US
Mailing Address - Phone:254-582-2351
Mailing Address - Fax:254-582-7017
Practice Address - Street 1:1400 EAST FRANKLIN STREET
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:TX
Practice Address - Zip Code:76645-0779
Practice Address - Country:US
Practice Address - Phone:254-582-2351
Practice Address - Fax:254-582-7017
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2348TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX410019703OtherRR MEDICARE
TX000000E940OtherBCBS
TX8F21428OtherTRAILBLAZER MEDICARE INDIVIDUAL PTAN
TX000000E94DOtherBCBS
TX0934804-01Medicaid
TX093480401Medicaid
TX000000E940OtherBCBS
TX000000E94DOtherBCBS
TX8F21428OtherTRAILBLAZER MEDICARE INDIVIDUAL PTAN
TX0460740001Medicare NSC