Provider Demographics
NPI:1700232345
Name:LOPEZ DE LA CRUZ, JOSE ORLEAN III
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:ORLEAN
Last Name:LOPEZ DE LA CRUZ
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3603 SOUTHRIDGE DR
Mailing Address - Street 2:APPARTMENT 2031
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-7739
Mailing Address - Country:US
Mailing Address - Phone:786-857-0656
Mailing Address - Fax:
Practice Address - Street 1:3603 SOUTHRIDGE DR
Practice Address - Street 2:APPARTMENT 2031
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7739
Practice Address - Country:US
Practice Address - Phone:786-857-0656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16-245246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX711149917Medicaid