=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477868305
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDGAR R DELACRUZ MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2010
-----------------------------------------------------
Last Update Date | 11/17/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 715 E SHAFER AVE
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44622-2053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-364-7764
-----------------------------------------------------
Fax | 330-343-8162
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 715 E SHAFER AVE
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44622-2053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-364-7764
-----------------------------------------------------
Fax | 330-343-8162
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | DR. EDGAR RODRIGUEZ DELACRUZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 330-364-7764
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 35043776
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------