Provider Demographics
NPI:1003815556
Name:DELUCA-PATWELL, DIANE (C-PED)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:
Last Name:DELUCA-PATWELL
Suffix:
Gender:F
Credentials:C-PED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 ARGYLE AVE
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-2600
Mailing Address - Country:US
Mailing Address - Phone:631-669-0721
Mailing Address - Fax:631-539-4370
Practice Address - Street 1:400 MONTAUK HWY
Practice Address - Street 2:SUITE 113
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4429
Practice Address - Country:US
Practice Address - Phone:631-321-1666
Practice Address - Fax:631-321-1666
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5033430001Medicare NSC