MEDICARE: DR. BRENDON DELPORT DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	2004008249	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00261949	OTHER		RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194721100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRENDON DELPORT DO

Provider Business Mailing Address
First Line	:	2828 N NATIONAL AVE
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65803-4306
Country	:	US
Telephone Number	:	417-837-4003
Fax Number	:	417-875-4782

Provider Business Practice Location Address
First Line	:	2828 N NATIONAL AVE
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65803-4306
Country	:	US
Telephone Number	:	417-837-4003
Fax Number	:	417-875-4782

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	06/16/2011

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Directions to “ DR. BRENDON DELPORT DO” Practice Location

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