Provider Demographics
NPI:1245899517
Name:DE LA HOZ, DAVID JAIRO
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:JAIRO
Last Name:DE LA HOZ
Suffix:
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 1:80 PIERS PARK LN APT 3213
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-2886
Mailing Address - Country:US
Mailing Address - Phone:786-253-8610
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:BUL 2
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-743-7972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2279390367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered