Basic Information
| Provider Information | |||||||||
| NPI: | 1467568311 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE LA CRUZ | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1554 | ||||||||
| Address2: | |||||||||
| City: | VEGA BAJA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 006941554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874547690 | ||||||||
| FaxNumber: | 7878072930 | ||||||||
| Practice Location | |||||||||
| Address1: | CARR 2 KM. 39.5 | ||||||||
| Address2: | BO. ALGARROBO SUITE 110 | ||||||||
| City: | VEGA BAJA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 006930000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878581580 | ||||||||
| FaxNumber: | 7878072930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 05/29/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 3860 | PR | Y | Allopathic & Osteopathic Physicians | Surgery | 208D00000X | 3860 | PR | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 4011902 | 05 | NJ | MEDICAID |