Healthcare Provider Details

I. General information

NPI: 1710813308
Provider Name (Legal Business Name): IVAN MANUEL DE LA CRUZ RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2685 CRESTON AVE APT 1J
BRONX NY
10468-3672
US

IV. Provider business mailing address

2685 CRESTON AVE APT 1J
BRONX NY
10468-3672
US

V. Phone/Fax

Practice location:
  • Phone: 917-587-8843
  • Fax:
Mailing address:
  • Phone: 917-587-8843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number813089-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: