Healthcare Provider Details

I. General information

NPI: 1689863847
Provider Name (Legal Business Name): ANTHONY C DE LA CRUZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2007
Last Update Date: 10/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 E DEL MAR BLVD APT# 334
PASADENA CA
91101-2770
US

IV. Provider business mailing address

65 REVERE ST
BOSTON MA
02114-4402
US

V. Phone/Fax

Practice location:
  • Phone: 626-354-2708
  • Fax:
Mailing address:
  • Phone: 626-354-2708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number231572
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: