Provider Demographics
NPI:1376588897
Name:DELORENZO, CHANDRA L (DO)
Entity type:Individual
Prefix:MRS
First Name:CHANDRA
Middle Name:L
Last Name:DELORENZO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 CONNABLE AVE
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2212
Mailing Address - Country:US
Mailing Address - Phone:231-487-4000
Mailing Address - Fax:
Practice Address - Street 1:416 CONNABLE AVE
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2212
Practice Address - Country:US
Practice Address - Phone:231-487-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011991208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1376588897Medicaid