Healthcare Provider Details

I. General information

NPI: 1609309905
Provider Name (Legal Business Name): MARK ANTHONY DELA CRUZ SY III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 09/26/2023
Certification Date: 07/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4867 W SUNSET BLVD
LOS ANGELES CA
90027-5969
US

IV. Provider business mailing address

11611 MOORPARK ST APT 6
NORTH HOLLYWOOD CA
91602-4229
US

V. Phone/Fax

Practice location:
  • Phone: 323-783-4011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberA171500
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: