Healthcare Provider Details

I. General information

NPI: 1366440323
Provider Name (Legal Business Name): MICHAEL V. DELOLLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 05/28/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 NW KINGS BLVD
CORVALLIS OR
97330-2521
US

IV. Provider business mailing address

1220 NW KINGS BLVD
CORVALLIS OR
97330-2521
US

V. Phone/Fax

Practice location:
  • Phone: 541-321-8552
  • Fax:
Mailing address:
  • Phone: 541-321-8552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG59726
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD11748
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD175003
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: