Provider Demographics
NPI:1356355218
Name:DELATORRE, HENRY G (MD)
Entity type:Individual
Prefix:DR
First Name:HENRY
Middle Name:G
Last Name:DELATORRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:HENRY
Other - Middle Name:
Other - Last Name:DELA TORRE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:90 BEAVER DR STE 214D
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-2441
Mailing Address - Country:US
Mailing Address - Phone:814-375-2287
Mailing Address - Fax:
Practice Address - Street 1:90 BEAVER DR STE 214D
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-2441
Practice Address - Country:US
Practice Address - Phone:814-375-2287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-027890-E208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008837220002Medicaid
PA195233Medicare ID - Type Unspecified
PA0008837220002Medicaid