Provider Demographics
NPI:1477597342
Name:DELADISMA, MARCONI DELEGERO (MD)
Entity Type:Individual
Prefix:
First Name:MARCONI
Middle Name:DELEGERO
Last Name:DELADISMA
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 1:2300 N ROCKTON AVE
Mailing Address - Street 2:ROCKFORD HEALTH PHYSICIANS
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-3619
Mailing Address - Country:US
Mailing Address - Phone:815-971-2000
Mailing Address - Fax:815-971-9501
Practice Address - Street 1:2300 N ROCKTON AVE
Practice Address - Street 2:ROCKFORD HEALTH PHYSICIANS
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3619
Practice Address - Country:US
Practice Address - Phone:815-971-2000
Practice Address - Fax:815-971-9501
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY241377207Q00000X
GA63412207Q00000X
IL036114984207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILI51419Medicare UPIN