Healthcare Provider Details

I. General information

NPI: 1235152919
Provider Name (Legal Business Name): MARY L. DE LUCA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 INDIAN SCHOOL RD NE SUITE 305
ALBUQUERQUE NM
87110-3816
US

IV. Provider business mailing address

4001 INDIAN SCHOOL RD NE SUITE 305
ALBUQUERQUE NM
87110-3816
US

V. Phone/Fax

Practice location:
  • Phone: 505-830-1100
  • Fax: 505-291-8441
Mailing address:
  • Phone: 505-830-1100
  • Fax: 505-291-8441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number97-217
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number97-217
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: