Provider Demographics
NPI:1033398342
Name:DELA CRUZ, BRANDON BALISACAN (IDC)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:BALISACAN
Last Name:DELA CRUZ
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC BOX 20101
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542
Mailing Address - Country:US
Mailing Address - Phone:910-450-6109
Mailing Address - Fax:
Practice Address - Street 1:D STREET
Practice Address - Street 2:BUILDING 202
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28542
Practice Address - Country:US
Practice Address - Phone:910-450-6109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-02
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman