Provider Demographics
NPI:1922257724
Name:DELAY, MARK ALLAN (IDC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLAN
Last Name:DELAY
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5039 GUNTER ST APT A
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-4067
Mailing Address - Country:US
Mailing Address - Phone:757-317-7040
Mailing Address - Fax:757-318-7123
Practice Address - Street 1:1875 COVE RD
Practice Address - Street 2:BLDG 3806
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23521-2911
Practice Address - Country:US
Practice Address - Phone:757-462-3780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman