Healthcare Provider Details

I. General information

NPI: 1528264801
Provider Name (Legal Business Name): MARIO A. DELISIO JR. S.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6770 MAYFIELD RD SUITE # 300
MAYFIELD HTS OH
44124-2299
US

IV. Provider business mailing address

5288 STRAWBERRY LN
WILLOUGHBY OH
44094-4373
US

V. Phone/Fax

Practice location:
  • Phone: 440-460-2822
  • Fax: 440-460-2825
Mailing address:
  • Phone: 440-942-3319
  • Fax: 440-460-2825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1101X
TaxonomyOphthalmic Assistant
License NumberNONE REQUIRED
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: