Provider Demographics
NPI:1598766412
Name:DELLER, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:DELLER
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:PO BOX 2366
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1086
Mailing Address - Country:US
Mailing Address - Phone:760-773-9750
Mailing Address - Fax:760-773-9294
Practice Address - Street 1:72780 COUNTRY CLUB DR
Practice Address - Street 2:SUITE 100
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4126
Practice Address - Country:US
Practice Address - Phone:760-773-9750
Practice Address - Fax:760-773-9292
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC29564207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA33959Medicare UPIN
CA00C295642Medicare PIN