Provider Demographics
NPI:1659492452
Name:DELUCA, CHARLES JOSEPH (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JOSEPH
Last Name:DELUCA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2246 PARK PL
Mailing Address - Street 2:
Mailing Address - City:NORTH MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-2812
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2429 GRAND AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-3219
Practice Address - Country:US
Practice Address - Phone:516-223-0528
Practice Address - Fax:516-223-0730
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2016-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005434-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400042587OtherMEDICARE GROUP MEMBER PTAN
NYA400042587OtherMEDICARE GROUP MEMBER PTAN
NYU66571Medicare UPIN