Provider Demographics
NPI:1437477460
Name:DE LA CERDA, CRYSTAL MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MICHELLE
Last Name:DE LA CERDA
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 1:18318 SNORKEL CV
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78255-3341
Mailing Address - Country:US
Mailing Address - Phone:210-912-2059
Mailing Address - Fax:
Practice Address - Street 1:333 N SANTA ROSA ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3108
Practice Address - Country:US
Practice Address - Phone:210-704-3718
Practice Address - Fax:210-704-4520
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-14
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5644208M00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
8CR137OtherBCBS TX
TX212706002OtherCSN
TXN5644OtherTEXAS MEDICAL LICENSE
TX212706001Medicaid