Provider Demographics
NPI:1235152919
Name:DE LUCA, MARY L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:DE LUCA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4001 INDIAN SCHOOL RD NE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3816
Mailing Address - Country:US
Mailing Address - Phone:505-830-1100
Mailing Address - Fax:505-291-8441
Practice Address - Street 1:4001 INDIAN SCHOOL RD NE
Practice Address - Street 2:SUITE 305
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3816
Practice Address - Country:US
Practice Address - Phone:505-830-1100
Practice Address - Fax:505-291-8441
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM97-2172084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMS7135Medicaid
AD1446170OtherDEA
AD1446170OtherDEA
NMS7135Medicaid