Provider Demographics
NPI:1588668925
Name:DELIDUKA, JOHN R (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:DELIDUKA
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 1:817 COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:WA
Mailing Address - Zip Code:98826-1316
Mailing Address - Country:US
Mailing Address - Phone:509-548-5815
Mailing Address - Fax:509-548-2510
Practice Address - Street 1:817 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:WA
Practice Address - Zip Code:98826-1316
Practice Address - Country:US
Practice Address - Phone:509-548-5815
Practice Address - Fax:509-548-1411
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00023297207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1008093Medicaid
WAA07544Medicare UPIN
WA000315335Medicare ID - Type UnspecifiedMEDICARE #