Healthcare Provider Details

I. General information

NPI: 1568701753
Provider Name (Legal Business Name): IVY DE LACRUZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2013
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 S CEDAR CREST BLVD STE 3500
ALLENTOWN PA
18103
US

IV. Provider business mailing address

PO BOX 783311
PHILADELPHIA PA
19178-3311
US

V. Phone/Fax

Practice location:
  • Phone: 610-969-0100
  • Fax: 610-969-0101
Mailing address:
  • Phone: 484-884-4500
  • Fax: 484-884-0699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberOS017172
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: