Provider Demographics
NPI:1598832826
Name:DELUCA, PETER S (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:S
Last Name:DELUCA
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 1:120 NEW YORK AVE
Mailing Address - Street 2:SUITE 6W
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743
Mailing Address - Country:US
Mailing Address - Phone:631-351-1144
Mailing Address - Fax:631-351-1143
Practice Address - Street 1:120 NEW YORK AVE
Practice Address - Street 2:SUITE 6W
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743
Practice Address - Country:US
Practice Address - Phone:631-351-1144
Practice Address - Fax:631-351-1143
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY139292207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00764250Medicaid
WEM401Medicare ID - Type UnspecifiedMEDICARE GROUP
NY00764250Medicaid
NY56A101Medicare ID - Type Unspecified