Provider Demographics
NPI:1598904740
Name:DELMAZO, MIGUEL B (MD)
Entity Type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:B
Last Name:DELMAZO
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 1:5403 OAK CREST LN
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-9029
Mailing Address - Country:US
Mailing Address - Phone:404-722-9753
Mailing Address - Fax:
Practice Address - Street 1:3215 MCCLURE BRIDGE RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096
Practice Address - Country:US
Practice Address - Phone:678-312-6200
Practice Address - Fax:678-312-6226
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA065651208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003114073FMedicaid
GA003114073LMedicaid
GA9738749OtherAETNA
GA52515750OtherBCBS
GA003114073NMedicaid
GA1489990OtherCOVENTRY
GA003114073HMedicaid
GA003114073KMedicaid
GA02378992OtherAMERIGROUP
GA003114073IMedicaid
GA003114073MMedicaid
GA003114073GMedicaid
GA1022567OtherWELLCARE
GA9672923OtherCIGNA
GA003114073JMedicaid