Healthcare Provider Details

I. General information

NPI: 1588078265
Provider Name (Legal Business Name): CELSO FERNANDO DE LA CRUZ LUQUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1599 NW 9TH AVE STE 203
BOCA RATON FL
33486-1310
US

IV. Provider business mailing address

1599 NW 9TH AVE STE 203
BOCA RATON FL
33486-1310
US

V. Phone/Fax

Practice location:
  • Phone: 561-338-8884
  • Fax: 561-338-5230
Mailing address:
  • Phone: 561-338-8884
  • Fax: 561-338-5230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberS3149
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN19764
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME162053
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: