Healthcare Provider Details

I. General information

NPI: 1578045027
Provider Name (Legal Business Name): DEREK ALEXANDER DELUCA PT, DPT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2018
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 BOSTON POST RD
SUDBURY MA
01776-2405
US

IV. Provider business mailing address

1500 E MEDICAL CENTER DR
ANN ARBOR MI
48109-5000
US

V. Phone/Fax

Practice location:
  • Phone: 978-295-5306
  • Fax: 978-440-8117
Mailing address:
  • Phone: 734-936-7070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number5501018825
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number24645
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: