Healthcare Provider Details

I. General information

NPI: 1457518839
Provider Name (Legal Business Name): JONETHAN P DELAUGHTER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 BELLEVIEW AVE SE
ROANOKE VA
24014-1838
US

IV. Provider business mailing address

2900 LAMB CIR
CHRISTIANSBURG VA
24073-6344
US

V. Phone/Fax

Practice location:
  • Phone: 540-266-6331
  • Fax:
Mailing address:
  • Phone: 540-731-2866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOT011592
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberN5647
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0102203459
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: