Provider Demographics
NPI:1467440776
Name:DE LA CRUZ, ANTONIO A (MD)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:A
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 1:197 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:NJ
Mailing Address - Zip Code:07044-2702
Mailing Address - Country:US
Mailing Address - Phone:973-857-0330
Mailing Address - Fax:973-857-0980
Practice Address - Street 1:197 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:NJ
Practice Address - Zip Code:07044-2702
Practice Address - Country:US
Practice Address - Phone:973-857-0330
Practice Address - Fax:973-857-0980
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06376600207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1500902Medicaid
NJ1500902Medicaid
H15667Medicare UPIN