Provider Demographics
NPI:1114994373
Name:DELUCA, RUSSELL ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:ROBERT
Last Name:DELUCA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 HOSPITAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061
Mailing Address - Country:US
Mailing Address - Phone:410-761-9896
Mailing Address - Fax:410-761-2250
Practice Address - Street 1:305 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061
Practice Address - Country:US
Practice Address - Phone:410-761-9896
Practice Address - Fax:410-761-2250
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0031551207RH0000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD408391100Medicaid
MD210121100Medicaid
MDK986Medicare ID - Type Unspecified