Provider Demographics
NPI:1710929377
Name:DELAFIELD, DOUGLAS J (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:DELAFIELD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:6400 DUTCHMANS PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3340
Practice Address - Country:US
Practice Address - Phone:502-894-2444
Practice Address - Fax:502-894-2445
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039459207Q00000X
KY28936207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY005717OtherSIHO
KY7100026500Medicaid
KY000000520323OtherANTHEM
KY3436186000OtherPASSPORT ADVANTAGE
IN100194360Medicaid
KY50017532OtherPASSPORT
KYP00415237OtherRAILROAD MEDICARE
KY005717OtherSIHO
IN100194360Medicaid
KY50017532OtherPASSPORT
IN196290MMM NORTONMedicare PIN