Provider Demographics
NPI:1437186335
Name:DELISIO, BRIAN J (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:J
Last Name:DELISIO
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 1:4838 E BASELINE RD STE 108
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4672
Mailing Address - Country:US
Mailing Address - Phone:480-981-2400
Mailing Address - Fax:480-981-2407
Practice Address - Street 1:4838 E BASELINE RD STE 108
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206
Practice Address - Country:US
Practice Address - Phone:480-981-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33634207LA0401X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ945131Medicaid
AZP00402237OtherRAILROAD MEDICARE
AZ105358Medicare ID - Type Unspecified
AZ945131Medicaid
I40812Medicare UPIN
AZP00402237OtherRAILROAD MEDICARE