Provider Demographics
NPI:1629382098
Name:DELECARIS, NICHOLAS A (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:A
Last Name:DELECARIS
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 RONALD REAGAN PKWY
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46123-5149
Practice Address - Country:US
Practice Address - Phone:317-217-3649
Practice Address - Fax:317-217-3474
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012032353207R00000X
IN01073713A207R00000X
MO2010020457390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201222640Medicaid
INP01348949Medicare PIN
IN267030044Medicare PIN