1053848028 NPI number — BRYAN JOSEPH GICANA DE LA CRUZ PT

Table of content: BRYAN JOSEPH GICANA DE LA CRUZ PT (NPI 1053848028)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053848028 NPI number — BRYAN JOSEPH GICANA DE LA CRUZ PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE LA CRUZ
Provider First Name:
BRYAN JOSEPH
Provider Middle Name:
GICANA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

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:
1053848028
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/22/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5211 79TH ST FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELMHURST
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11373-4112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
848-667-0943
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
865 CYPRESS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIDGEWOOD
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11385-4724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
848-667-0943
Provider Business Practice Location Address Fax Number:
848-667-0943
Provider Enumeration Date:
05/22/2017

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: 225100000X , with the licence number:  041569 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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