Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | 01059798 | IN |
N | 2084N0402X | Child Neurologist | 01059798A | IN |
NPI | 1003870791 |
---|---|
Provider Name | Dr. Pablito Dela Cruz |
First Address | Terre Haute, IN 47802-4034 |
Second Address | Terre Haute, IN 47802-4034 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/04/2006 |
Last Update Date | 20/12/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200507050 | (05) | IN |
F60761 | (02) |