MEDICARE: JESSICA CORRAL DELACRUZ M.D.

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	208000000X	Pediatrics Physician	35149	SC

General Provider Information

NPI Number	:	1720343346
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA CORRAL DELACRUZ M.D.

Provider Business Mailing Address
First Line	:	536 W MARTINTOWN RD
Second Line	:
City	:	NORTH AUGUSTA
State	:	SC
Zip	:	29841-1101
Country	:	US
Telephone Number	:	803-510-0007
Fax Number	:	803-510-0144

Provider Business Practice Location Address
First Line	:	536 W MARTINTOWN RD
Second Line	:
City	:	NORTH AUGUSTA
State	:	SC
Zip	:	29841-1101
Country	:	US
Telephone Number	:	803-510-0007
Fax Number	:	803-510-0144

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2012
Last Update Date	:	07/06/2015

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