Provider Demographics
NPI:1588612345
Name:DELUCIA III, ALPHONSE (MD)
Entity Type:Individual
Prefix:
First Name:ALPHONSE
Middle Name:
Last Name:DELUCIA III
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 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-740-5293
Mailing Address - Fax:
Practice Address - Street 1:1500 E MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5000
Practice Address - Country:US
Practice Address - Phone:734-936-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI053184208G00000X
MI4301053184208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4211999Medicaid
MI1417961137OtherBCBSM - BRONSON
MI1588612345Medicaid
MI03904931OtherBLUE CROSS BLUE SHIELD
MI4211999Medicaid
MIF96500Medicare UPIN
MI1417961137OtherBCBSM - BRONSON