Provider Demographics
NPI:1851701213
Name:DELIBERATO, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:DELIBERATO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5000 W SLAUGHTER LN STE 100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-4015
Practice Address - Country:US
Practice Address - Phone:512-654-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-06
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT015720207Q00000X
TXR1735207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine