Provider Demographics
NPI:1508544305
Name:DELUCA, CHARLES PATRICK
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:PATRICK
Last Name:DELUCA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CHARLIE
Other - Middle Name:
Other - Last Name:DELUCA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:409 E 9 MILE RD APT 402
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-3027
Mailing Address - Country:US
Mailing Address - Phone:517-402-2848
Mailing Address - Fax:
Practice Address - Street 1:3950 BEAUBIEN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2166
Practice Address - Country:US
Practice Address - Phone:313-832-9639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS