Provider Demographics
NPI:1790967198
Name:SELBYVILLE INTERNAL MEDICINE LLC
Entity Type:Organization
Organization Name:SELBYVILLE INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIO
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:DEPENA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-436-6394
Mailing Address - Street 1:18 MASON DIXON SHOPPING CTR
Mailing Address - Street 2:
Mailing Address - City:SELBYVILLE
Mailing Address - State:DE
Mailing Address - Zip Code:19975-9641
Mailing Address - Country:US
Mailing Address - Phone:302-436-6394
Mailing Address - Fax:302-436-6398
Practice Address - Street 1:18 MASON DIXON SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:SELBYVILLE
Practice Address - State:DE
Practice Address - Zip Code:19975-9641
Practice Address - Country:US
Practice Address - Phone:302-436-6394
Practice Address - Fax:302-436-6398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10005626174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC10005626OtherDE STATE LICENSE
DEC10005626OtherDE STATE LICENSE
DEBD6282761OtherDEA