Healthcare Provider Details

I. General information

NPI: 1194050989
Provider Name (Legal Business Name): JOANNA M DELUCO O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2009
Last Update Date: 10/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14915 W MICHIGAN AVE
MARSHALL MI
49068-8504
US

IV. Provider business mailing address

14915 W MICHIGAN AVE
MARSHALL MI
49068-8504
US

V. Phone/Fax

Practice location:
  • Phone: 269-781-9863
  • Fax: 269-781-9864
Mailing address:
  • Phone: 269-781-9863
  • Fax: 269-781-9864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004545
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: