Provider Demographics
NPI:1457897290
Name:DELLERSON, GARY JAY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:JAY
Last Name:DELLERSON
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 1:2402 EMBASSY DR
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-1013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2402 EMBASSY DR
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-1013
Practice Address - Country:US
Practice Address - Phone:561-689-4747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 15790208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME 15790OtherSTATE OF FLORIDA DEPT. OF HEALTH DIVISION OF MEDICAL QUALITY INSURANCE