Healthcare Provider Details

I. General information

NPI: 1649595653
Provider Name (Legal Business Name): LUCY MARIA DE LA CRUZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2010
Last Update Date: 11/27/2023
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8081 INNOVATION PARK DR
FAIRFAX VA
22031-4867
US

IV. Provider business mailing address

3400 SPRUCE ST 4 SILVERSTEIN
PHILADELPHIA PA
19104-4206
US

V. Phone/Fax

Practice location:
  • Phone: 571-472-4724
  • Fax: 571-472-0241
Mailing address:
  • Phone: 215-662-2033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberMD454888
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101265995
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: