Provider Demographics
NPI:1447261896
Name:ANTONIO A. DE LA CRUZ, MD., PA
Entity type:Organization
Organization Name:ANTONIO A. DE LA CRUZ, MD., PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:A
Authorized Official - Last Name:DE LA CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-397-0772
Mailing Address - Street 1:25 PORSCHE DR
Mailing Address - Street 2:
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-3538
Mailing Address - Country:US
Mailing Address - Phone:732-397-0772
Mailing Address - Fax:
Practice Address - Street 1:559 BROAD ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-4503
Practice Address - Country:US
Practice Address - Phone:973-622-3890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03502300207K00000X, 207QA0401X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
Not Answered207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2066807Medicaid
D66416Medicare UPIN
456140Medicare ID - Type Unspecified