Provider Demographics
NPI:1669442992
Name:DELUCA, KEVIN D (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:D
Last Name:DELUCA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:215 ELMWOOD AVE
Mailing Address - Street 2:PO BOX 2169
Mailing Address - City:ELMIRA HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:14903-1736
Mailing Address - Country:US
Mailing Address - Phone:607-733-3639
Mailing Address - Fax:607-733-1292
Practice Address - Street 1:600 ROE AVE
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1629
Practice Address - Country:US
Practice Address - Phone:607-733-3639
Practice Address - Fax:607-733-1292
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY209552207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02157293Medicaid
NYCC8636Medicare PIN
NYCC6258Medicare PIN