Healthcare Provider Details

I. General information

NPI: 1669460655
Provider Name (Legal Business Name): RAFAEL DE LA CRUZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 MEMORIAL DR STE 230B
ALTON IL
62002-6705
US

IV. Provider business mailing address

670 MASON RIDGE CENTER DR STE. 300
SAINT LOUIS MO
63141-8573
US

V. Phone/Fax

Practice location:
  • Phone: 636-344-2014
  • Fax: 314-747-1476
Mailing address:
  • Phone: 636-344-2014
  • Fax: 314-747-1476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number2008007441
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number036-108921
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: