Provider Demographics
NPI:1376535484
Name:DE LA CRUZ, FAUSTO A (MD)
Entity Type:Individual
Prefix:MR
First Name:FAUSTO
Middle Name:A
Last Name:DE LA CRUZ
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:603 N FLAMINGO RD
Mailing Address - Street 2:#357
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-1023
Mailing Address - Country:US
Mailing Address - Phone:954-450-8488
Mailing Address - Fax:954-450-8860
Practice Address - Street 1:603 N FLAMINGO RD
Practice Address - Street 2:#357
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1023
Practice Address - Country:US
Practice Address - Phone:954-450-8488
Practice Address - Fax:954-950-8860
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2009-11-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME0048782207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379570500Medicaid
FLK5249Medicare PIN
B79951Medicare UPIN