Basic Information
| Provider Information | |||||||||
| NPI: | 1568677300 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DELUCA | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5365 W ATLANTIC AVE | ||||||||
| Address2: | SUITE 504 | ||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334848172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5612419300 | ||||||||
| FaxNumber: | 5612419339 | ||||||||
| Practice Location | |||||||||
| Address1: | 13945 N US HIGHWAY 441 | ||||||||
| Address2: | |||||||||
| City: | LADY LAKE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321598924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522773500 | ||||||||
| FaxNumber: | 3522773498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 01/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | ME107250 | FL | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081P2900X | ME107250 | FL | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 208VP0000X | ME107250 | FL | N | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0014X | ME107250 | FL | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | ME107250 | 01 | FL | FLORIDA LICENSE | OTHER |