Provider Demographics
NPI:1699795237
Name:DE LA CRUZ, LOURDES (MD)
Entity type:Individual
Prefix:
First Name:LOURDES
Middle Name:
Last Name:DE LA CRUZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3090 FRANDORAS CIRCLE
Mailing Address - Street 2:
Mailing Address - City:OAKLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94561
Mailing Address - Country:US
Mailing Address - Phone:925-642-1742
Mailing Address - Fax:
Practice Address - Street 1:3090 FRANDORAS CIRCLE
Practice Address - Street 2:
Practice Address - City:OAKLEY
Practice Address - State:CA
Practice Address - Zip Code:94561
Practice Address - Country:US
Practice Address - Phone:925-642-1742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42190208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A421900Medicaid
CA00A421901Medicare ID - Type Unspecified
CAE99014Medicare UPIN