Provider Demographics
NPI:1629045802
Name:DELISLE, JEFFREY D (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:D
Last Name:DELISLE
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 1:350 POWER AVE
Mailing Address - Street 2:POB 635
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534-2447
Mailing Address - Country:US
Mailing Address - Phone:518-828-9300
Mailing Address - Fax:518-751-1038
Practice Address - Street 1:350 POWER AVE
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-2447
Practice Address - Country:US
Practice Address - Phone:518-828-9300
Practice Address - Fax:518-751-1038
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-07
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY15452912084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00347562Medicaid
NY00347562Medicaid
NYDD1115Medicare ID - Type Unspecified