Basic Information
Provider Information | |||||||||
NPI: | 1437477460 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DE LA CERDA | ||||||||
FirstName: | CRYSTAL | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 18318 SNORKEL CV | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782553341 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2109122059 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 333 N SANTA ROSA ST | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782073108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2107043718 | ||||||||
FaxNumber: | 2107044520 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/14/2010 | ||||||||
LastUpdateDate: | 11/06/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | N5644 | TX | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 208000000X | N5644 | TX | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 8CR137 | 01 |   | BCBS TX | OTHER | 212706002 | 01 | TX | CSN | OTHER | N5644 | 01 | TX | TEXAS MEDICAL LICENSE | OTHER | 212706001 | 05 | TX |   | MEDICAID |