Provider Demographics
NPI:1639319254
Name:CLINICA MEDICA DR RENE DELGADO, INC
Entity Type:Organization
Organization Name:CLINICA MEDICA DR RENE DELGADO, INC
Other - Org Name:CLINICA MEDICA FAMILIAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:DOURRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-996-9681
Mailing Address - Street 1:189 MEDICAL WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-4905
Mailing Address - Country:US
Mailing Address - Phone:770-996-9681
Mailing Address - Fax:770-996-9683
Practice Address - Street 1:189 MEDICAL WAY
Practice Address - Street 2:SUITE B
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-4905
Practice Address - Country:US
Practice Address - Phone:770-996-9681
Practice Address - Fax:770-996-9683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-22
Last Update Date:2009-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA027722207Q00000X
GA014308207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000348675AMedicaid