Provider Demographics
NPI:1740280882
Name:DELUCCA, MANNY (MD)
Entity type:Individual
Prefix:
First Name:MANNY
Middle Name:
Last Name:DELUCCA
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 1:26224 N TATUM BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-7500
Mailing Address - Country:US
Mailing Address - Phone:480-563-1111
Mailing Address - Fax:480-563-3044
Practice Address - Street 1:26224 N TATUM BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-7500
Practice Address - Country:US
Practice Address - Phone:480-563-1111
Practice Address - Fax:480-563-3044
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27388208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
12-00497OtherUNITED HEALTHCARE
210610OtherMAYO
1Z9385OtherHEALTHNET
AZ484527001Medicaid
AZ0770330OtherBLUE CROSS BLUE SHIELD
1229050OtherFIRST HEALTH
5225829OtherCCN