Healthcare Provider Details

I. General information

NPI: 1972578284
Provider Name (Legal Business Name): ANTONIO A. DE LA CRUZ MIRANDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARIMED PLZ B-1 CALLE SANTA CRUZ SUITE 403-404
BAYAMON PR
00961-6928
US

IV. Provider business mailing address

B-17 CALLE POPPY PARQUE FORESTAL
SAN JUAN PR
00926
US

V. Phone/Fax

Practice location:
  • Phone: 787-798-7070
  • Fax: 787-787-2107
Mailing address:
  • Phone: 787-798-7070
  • Fax: 787-787-2107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number12964
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: