Healthcare Provider Details

I. General information

NPI: 1619453412
Provider Name (Legal Business Name): ANGEL CRISTIAN DE LA CRUZ TEJADA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2018
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HEALTHCARE WAY UNIT 103
NORTH VENICE FL
34275-3670
US

IV. Provider business mailing address

PO BOX 947407
ATLANTA GA
30394-7407
US

V. Phone/Fax

Practice location:
  • Phone: 941-261-0160
  • Fax: 941-261-0165
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME180359
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: