Healthcare Provider Details

I. General information

NPI: 1003815556
Provider Name (Legal Business Name): DIANE DELUCA-PATWELL C-PED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MONTAUK HWY SUITE 113
WEST ISLIP NY
11795-4429
US

IV. Provider business mailing address

105 ARGYLE AVE
BABYLON NY
11702-2600
US

V. Phone/Fax

Practice location:
  • Phone: 631-321-1666
  • Fax: 631-321-1666
Mailing address:
  • Phone: 631-669-0721
  • Fax: 631-539-4370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: