Provider Demographics
NPI:1720009574
Name:DELAURA, ERIC J (DO)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:J
Last Name:DELAURA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 VALLEY STREAM PKWY STE 100
Mailing Address - Street 2:ATTN: CREDENTIALING DEPT.
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-1407
Mailing Address - Country:US
Mailing Address - Phone:610-644-8900
Mailing Address - Fax:610-644-8909
Practice Address - Street 1:1050 GALLOPING HILL RD STE 102
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-7980
Practice Address - Country:US
Practice Address - Phone:908-686-1350
Practice Address - Fax:908-686-1382
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2325192085R0202X
NJ25MB077472002085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0167215Medicaid
NJ140689ZB70Medicare PIN
NY787S01Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID
NJ0167215Medicaid