Provider Demographics
NPI:1245047372
Name:DELUCA, MARIO F (HIS)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:F
Last Name:DELUCA
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N87W16459 APPLETON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-2888
Mailing Address - Country:US
Mailing Address - Phone:262-293-2592
Mailing Address - Fax:262-501-4599
Practice Address - Street 1:N87W16459 APPLETON AVE STE B
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-2888
Practice Address - Country:US
Practice Address - Phone:262-293-2592
Practice Address - Fax:262-501-4599
Is Sole Proprietor?:No
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2112-60237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist