Healthcare Provider Details

I. General information

NPI: 1689920548
Provider Name (Legal Business Name): ENRIQUE JOSE DE LA CRUZ HERNANDEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2012
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13045 SUMMERFIELD SQUARE DR
RIVERVIEW FL
33578-7402
US

IV. Provider business mailing address

425 W COLONIAL DR STE 303
ORLANDO FL
32804-6863
US

V. Phone/Fax

Practice location:
  • Phone: 813-672-1385
  • Fax: 813-672-8904
Mailing address:
  • Phone: 833-702-8383
  • Fax: 689-304-0303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME143269
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: