Provider Demographics
NPI:1932290384
Name:DELVALLE, RICHARD K (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:K
Last Name:DELVALLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 BURNETT DR
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-9519
Mailing Address - Country:US
Mailing Address - Phone:217-321-9310
Mailing Address - Fax:
Practice Address - Street 1:1304 BURNETT DR
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-9519
Practice Address - Country:US
Practice Address - Phone:217-321-9310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-075738207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036075738Medicaid
IL036075738Medicaid
K24185Medicare ID - Type Unspecified