Provider Demographics
NPI:1336444777
Name:DE LA CRUZ, ANGEL RAMON (MD)
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:RAMON
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 1:1137 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07011-2386
Mailing Address - Country:US
Mailing Address - Phone:973-773-0303
Mailing Address - Fax:973-773-0004
Practice Address - Street 1:1137 MAIN AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-2386
Practice Address - Country:US
Practice Address - Phone:973-405-3900
Practice Address - Fax:973-928-1899
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-16
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09042900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0300161Medicaid
FL003959100Medicaid