Basic Information
| Provider Information | |||||||||
| NPI: | 1740235738 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE LUCA | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25595 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336225595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278232188 | ||||||||
| FaxNumber: | 7278280723 | ||||||||
| Practice Location | |||||||||
| Address1: | 7171 N DALE MABRY HWY | ||||||||
| Address2: | STE 404 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336142665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139321510 | ||||||||
| FaxNumber: | 8132384378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 06/27/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME94019 | FL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PE0005X | ME94019 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Undersea and Hyperbaric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 29406 | 01 | FL | BCBS OF FLORIDA | OTHER | P01037262 | 01 | FL | RAILROAD MEDICARE ATTACHED TO GRP# DQ1103 | OTHER | 273731100 | 05 | FL | MEDICAID |