=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376921114
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATHANIEL R. DE LA CRUZ MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2015
-----------------------------------------------------
Last Update Date | 06/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1512 E GRIFFIN PKWY STE 2
-----------------------------------------------------
City | MISSION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-519-7088
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1512 E GRIFFIN PKWY STE 2
-----------------------------------------------------
City | MISSION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78572-2422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-519-7088
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | R6769
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | BP10052598
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------