Provider Demographics
NPI:1376921114
Name:DE LA CRUZ, NATHANIEL R (MD)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:R
Last Name:DE LA CRUZ
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 1:1512 E GRIFFIN PKWY STE 2
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-2422
Mailing Address - Country:US
Mailing Address - Phone:956-519-7088
Mailing Address - Fax:
Practice Address - Street 1:1512 E GRIFFIN PKWY STE 2
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572
Practice Address - Country:US
Practice Address - Phone:956-519-7088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-13
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR6769207Q00000X
TXBP10052598207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine