Healthcare Provider Details

I. General information

NPI: 1538430244
Provider Name (Legal Business Name): DELALI OHUI BLAVO DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2012
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 SOUTHCREST CIR STE 202
SOUTHAVEN MS
38671-6719
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD
MEMPHIS TN
38120-9401
US

V. Phone/Fax

Practice location:
  • Phone: 901-763-3636
  • Fax: 662-536-2282
Mailing address:
  • Phone:
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number4188
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number23064
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: