Healthcare Provider Details

I. General information

NPI: 1104630003
Provider Name (Legal Business Name): MR. REYNALDO DE LA CRUZ JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2025
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7420 MARLBORO PIKE
FORESTVILLE MD
20747-4343
US

IV. Provider business mailing address

4508 HARVEST RD
TEMPLE HILLS MD
20748-3612
US

V. Phone/Fax

Practice location:
  • Phone: 301-736-0240
  • Fax: 240-628-7472
Mailing address:
  • Phone: 202-945-2893
  • Fax: 240-628-7472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAC007598
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024192953
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1194340
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: