Provider Demographics
NPI:1417946468
Name:DELUCA, MATTHEW J
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:DELUCA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 STATE ST
Mailing Address - Street 2:
Mailing Address - City:BADEN
Mailing Address - State:PA
Mailing Address - Zip Code:15005-1737
Mailing Address - Country:US
Mailing Address - Phone:724-869-1870
Mailing Address - Fax:724-869-8113
Practice Address - Street 1:400 STATE ST
Practice Address - Street 2:
Practice Address - City:BADEN
Practice Address - State:PA
Practice Address - Zip Code:15005-1737
Practice Address - Country:US
Practice Address - Phone:724-869-1870
Practice Address - Fax:724-869-8113
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG 001100152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012700740004Medicaid
PA0439150001Medicare NSC
PAU20422Medicare UPIN
PA685170Medicare PIN