Provider Demographics
NPI:1467568311
Name:DE LA CRUZ, JUAN (MD)
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:
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:PO BOX 1554
Mailing Address - Street 2:
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00694-1554
Mailing Address - Country:US
Mailing Address - Phone:787-454-7690
Mailing Address - Fax:787-807-2930
Practice Address - Street 1:CARR 2 KM. 39.5
Practice Address - Street 2:BO. ALGARROBO SUITE 110
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693-0000
Practice Address - Country:US
Practice Address - Phone:787-858-1580
Practice Address - Fax:787-807-2930
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3860208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4011902Medicaid
PRHP503AMedicare UPIN
NJ4011902Medicaid