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General NPI Number Information
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NPI Number | 1669460655
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Entity Type | Individual
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Provider Name | RAFAEL DE LA CRUZ MD
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Gender | Male
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Dates
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Enumeration Date | 10/12/2005
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Last Update Date | 02/26/2021
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Provider Practice Location Address
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Address Line | 4 MEMORIAL DR STE 230B
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City | ALTON
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State | IL
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Zip | 62002-6705
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Country | US
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Telephone | 636-344-2014
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Fax | 314-747-1476
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Provider Business Mailing Address
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Address Line | 670 MASON RIDGE CENTER DR STE. 300
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City | SAINT LOUIS
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State | MO
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Zip | 63141-8573
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Country | US
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Telephone | 636-344-2014
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Fax | 314-747-1476
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RI0200X
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Taxonomy Name | Infectious Disease Physician
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License Number | 2008007441
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 207RI0200X
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Taxonomy Name | Infectious Disease Physician
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License Number | 036-108921
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License Number State | IL
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