Provider Demographics
NPI:1720297963
Name:DELSTON, DAMON DECKELMAN (MD)
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:DECKELMAN
Last Name:DELSTON
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 1:665 NEWARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306
Mailing Address - Country:US
Mailing Address - Phone:201-963-9331
Mailing Address - Fax:212-581-9860
Practice Address - Street 1:665 NEWARK AVENUE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306
Practice Address - Country:US
Practice Address - Phone:201-963-9331
Practice Address - Fax:212-581-9860
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA044016002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7151501Medicaid
J001208OtherCHAMPUS
C54502Medicare UPIN
NJ7151501Medicaid