Healthcare Provider Details

I. General information

NPI: 1518959337
Provider Name (Legal Business Name): GEORGE V DELAND MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 02/17/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 N. SIXTH AVENUE
SANDPOINT ID
83864-5396
US

IV. Provider business mailing address

PO BOX 2160
SANDPOINT ID
83864-0908
US

V. Phone/Fax

Practice location:
  • Phone: 208-265-2242
  • Fax: 208-265-8214
Mailing address:
  • Phone: 208-265-2242
  • Fax: 208-265-8214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberM6447
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM-6447
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: