Healthcare Provider Details

I. General information

NPI: 1245276278
Provider Name (Legal Business Name): EDILBERTO DE LA CRUZ P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 06/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST
BALTIMORE MD
21287-0005
US

IV. Provider business mailing address

PO BOX 64382
BALTIMORE MD
21264-4382
US

V. Phone/Fax

Practice location:
  • Phone: 301-652-2707
  • Fax: 301-907-4570
Mailing address:
  • Phone: 410-550-8432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberC02961
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: