MEDICARE: ELISE C DELUKE M.D., PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1679937916
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELISE C DELUKE M.D., PLLC

Provider Business Mailing Address
First Line	:	4949 MAIN ST
Second Line	:
City	:	AMHERST
State	:	NY
Zip	:	14226-4070
Country	:	US
Telephone Number	:	716-970-4140
Fax Number	:

Provider Business Practice Location Address
First Line	:	4949 MAIN ST
Second Line	:
City	:	AMHERST
State	:	NY
Zip	:	14226-4070
Country	:	US
Telephone Number	:	716-970-4140
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ELISE C DELUKE
Credential	:	MD
Telephone Number	:	716-970-4140

Provider Enumeration Date	:	04/13/2016
Last Update Date	:	10/04/2016

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