Provider Demographics
NPI:1538104757
Name:DELASHMET, GORDON BARTLETT JR (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:BARTLETT
Last Name:DELASHMET
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:901-227-3255
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:1200 N STATE ST
Practice Address - Street 2:SUITE 500
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2000
Practice Address - Country:US
Practice Address - Phone:601-352-2273
Practice Address - Fax:601-714-3415
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS10265207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00015359Medicaid
MSB66153Medicare UPIN
MS110000473Medicare ID - Type Unspecified