1679673685 NPI number — MANUELA M DELACRUZ M.D.

Table of content: MANUELA M DELACRUZ M.D. (NPI 1679673685)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679673685 NPI number — MANUELA M DELACRUZ M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DELACRUZ
Provider First Name:
MANUELA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679673685
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
160 KINGSLEY LN
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
NORFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23505-4600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-889-6677
Provider Business Mailing Address Fax Number:
757-889-6652

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 KINGSLEY LN
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23505-4600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-889-6677
Provider Business Practice Location Address Fax Number:
757-889-6652
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  0101042498 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 415671 . This is a "MDIPA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 5819199 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4413117 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1679673685 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 15504 . This is a "OPTIMA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 325099 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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