Provider Demographics
NPI:1275593907
Name:DELACRUZ, EDGAR RODRIGUEZ (MD)
Entity Type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:RODRIGUEZ
Last Name:DELACRUZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 E SHAFER AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-2053
Mailing Address - Country:US
Mailing Address - Phone:330-364-7764
Mailing Address - Fax:330-343-8162
Practice Address - Street 1:715 E SHAFER AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-2053
Practice Address - Country:US
Practice Address - Phone:330-364-7764
Practice Address - Fax:330-343-8162
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-25
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043776174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0526112Medicaid
OH0526351Medicare ID - Type Unspecified
OH0526112Medicaid