Basic Information
| Provider Information | |||||||||
| NPI: | 1114088697 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE LA CRUZ | ||||||||
| FirstName: | PAULA | ||||||||
| MiddleName: | VANESSA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DE LA CRUZ | ||||||||
| OtherFirstName: | VANESSA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2000 ALAMEDA DE LAS PULGAS STE 235 | ||||||||
| Address2: | |||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944031185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505732043 | ||||||||
| FaxNumber: | 6505732841 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 EMELINE AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950601976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314544170 | ||||||||
| FaxNumber: | 8314544663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 236555 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | A77095 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | ZZZ91891Z | 01 | CA | COUNTY OF SANTA CRUZ MEDICARE GROUP PTAN# | OTHER | FHC 70042F | 01 | CA | COUNTY OF SANTA CRUZ MEDI-CAL GROUP# | OTHER | ZZZ92069Z | 01 | CA | COUNTY OF SANTA CRUZ MEDICARE GROUP PTAN# | OTHER | FHC 70044F | 01 | CA | COUNTY OF SANTA CRUZ MEDI-CAL GROUP # | OTHER | ZZZ91892Z | 01 | CA | COUNTY OF SANTA CRUZ MEDICARE GROUP PTAN# | OTHER |