Provider Demographics
NPI:1851908859
Name:DUCLOS, DEJA
Entity Type:Individual
Prefix:
First Name:DEJA
Middle Name:
Last Name:DUCLOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:981 CASA DEL SOL CIR
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-7280
Mailing Address - Country:US
Mailing Address - Phone:407-692-2622
Mailing Address - Fax:
Practice Address - Street 1:12201 RESEARCH PAKWY, SUITE 300
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826
Practice Address - Country:US
Practice Address - Phone:407-823-2744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program