Provider Demographics
NPI:1841262680
Name:DE LA CRUZ, MARIJO S (DO)
Entity type:Individual
Prefix:DR
First Name:MARIJO
Middle Name:S
Last Name:DE LA CRUZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1954 IOWA AVE NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-3426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10150 HIGHLAND MANOR DR STE 240
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-9750
Practice Address - Country:US
Practice Address - Phone:813-259-1013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL058051207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261550900Medicaid
FL261550900Medicaid
FL03217Medicare ID - Type Unspecified