Healthcare Provider Details

I. General information

NPI: 1912002882
Provider Name (Legal Business Name): DAVID L DELOSO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 06/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 VETERANS MEMORIAL DR
MOUNT VERNON IL
62864-5924
US

IV. Provider business mailing address

PO BOX 155
CHRISTOPHER IL
62822-0155
US

V. Phone/Fax

Practice location:
  • Phone: 618-244-6544
  • Fax: 618-244-6577
Mailing address:
  • Phone: 618-724-1624
  • Fax: 618-724-4628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036089974
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: