Provider Demographics
NPI:1649908112
Name:DE LA CRUZ CHALJUB, KELVIN ANTONIO (CSFA)
Entity type:Individual
Prefix:
First Name:KELVIN
Middle Name:ANTONIO
Last Name:DE LA CRUZ CHALJUB
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 COVE POINT RD
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-3025
Mailing Address - Country:US
Mailing Address - Phone:386-500-6225
Mailing Address - Fax:
Practice Address - Street 1:1850 STATE STREET
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150
Practice Address - Country:US
Practice Address - Phone:812-944-7701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
16-724156F00000X
FL16-724246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical TechnologistGroup - Multi-Specialty
No156F00000XEye and Vision Services ProvidersTechnician/Technologist