Healthcare Provider Details

I. General information

NPI: 1245245117
Provider Name (Legal Business Name): JOHN WILLIAM DELUCA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 11/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 30TH ST SUITE 207
BOULDER CO
80301-1088
US

IV. Provider business mailing address

PO BOX 18553
BOULDER CO
80308-1553
US

V. Phone/Fax

Practice location:
  • Phone: 303-746-4402
  • Fax:
Mailing address:
  • Phone: 303-746-4402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number2846
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number6301006649
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: