Provider Demographics
NPI:1578045027
Name:DELUCA, DEREK ALEXANDER (PT, DPT, CSCS)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:ALEXANDER
Last Name:DELUCA
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-5000
Mailing Address - Country:US
Mailing Address - Phone:734-936-7070
Mailing Address - Fax:
Practice Address - Street 1:141 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:SUDBURY
Practice Address - State:MA
Practice Address - Zip Code:01776-2405
Practice Address - Country:US
Practice Address - Phone:978-295-5306
Practice Address - Fax:978-440-8117
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-31
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010188252251X0800X
MA24645225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic