Provider Demographics
NPI:1609849918
Name:DELALLE, IVANA (MD)
Entity Type:Individual
Prefix:
First Name:IVANA
Middle Name:
Last Name:DELALLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:670 ALBANY ST
Practice Address - Street 2:FLOOR 3 ROOM 310
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2646
Practice Address - Country:US
Practice Address - Phone:617-414-5314
Practice Address - Fax:617-414-5315
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207664207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110002861AMedicaid
MARX2507Medicare PIN
MAH38124Medicare UPIN