Provider Demographics
NPI:1245398833
Name:DE LA CRUZ, SOFIA A (MD)
Entity Type:Individual
Prefix:
First Name:SOFIA
Middle Name:A
Last Name:DE LA CRUZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 W 175TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-8031
Mailing Address - Country:US
Mailing Address - Phone:212-927-8873
Mailing Address - Fax:212-927-8914
Practice Address - Street 1:560 W 175TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-8031
Practice Address - Country:US
Practice Address - Phone:212-927-8873
Practice Address - Fax:212-927-8914
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1547712080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00860944Medicaid
NY00860944Medicaid