Provider Demographics
NPI:1316928781
Name:DELACRUZ, FREDY E (MD)
Entity type:Individual
Prefix:
First Name:FREDY
Middle Name:E
Last Name:DELACRUZ
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 1:6100 MINTON RD NW
Mailing Address - Street 2:STE 101
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-1975
Mailing Address - Country:US
Mailing Address - Phone:321-722-1984
Mailing Address - Fax:321-722-0028
Practice Address - Street 1:6100 MINTON RD NW
Practice Address - Street 2:STE 101
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-1975
Practice Address - Country:US
Practice Address - Phone:321-722-1984
Practice Address - Fax:321-722-0028
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME39547208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D54235Medicare UPIN
FL31136Medicare ID - Type Unspecified