Provider Demographics
NPI:1669460655
Name:DE LA CRUZ, RAFAEL (MD)
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:DE LA CRUZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE. 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:636-344-2014
Mailing Address - Fax:314-747-1476
Practice Address - Street 1:4 MEMORIAL DR STE 230B
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6705
Practice Address - Country:US
Practice Address - Phone:636-344-2014
Practice Address - Fax:314-747-1476
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2008007441207RI0200X
IL036-108921207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1669460655Medicaid
MO124700005Medicare PIN