=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043445539
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRYSTAL LYNN DELUCA O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2009
-----------------------------------------------------
Last Update Date | 06/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 950 CAMPBELL AVE
-----------------------------------------------------
City | WEST HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06516-2770
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-932-5711
-----------------------------------------------------
Fax | 203-479-8118
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6406 S 164TH CIR
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68135-6376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-319-9257
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2785
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1341
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------