Provider Demographics
NPI:1477868305
Name:EDGAR R DELACRUZ MD INC
Entity Type:Organization
Organization Name:EDGAR R DELACRUZ MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:RODRIGUEZ
Authorized Official - Last Name:DELACRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-364-7764
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-16
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043776174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3090533Medicaid
OH0526351Medicare PIN
OHA-80554Medicare UPIN