Healthcare Provider Details

I. General information

NPI: 1588288435
Provider Name (Legal Business Name): ELLIOT M DEBLIECK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2020
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 E SIGLER AVE STE A
MEMPHIS MO
63555-1726
US

IV. Provider business mailing address

PO BOX 1475
DES MOINES IA
50305-1475
US

V. Phone/Fax

Practice location:
  • Phone: 660-465-2828
  • Fax:
Mailing address:
  • Phone: 515-643-8678
  • Fax: 515-643-5802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2023030282
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR-11913
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: