Basic Information
Provider Information | |||||||||
NPI: | 1437604600 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CESAR CRUZ, M.D. A PROFESSIONAL MEDICAL CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 415 W ROUTE 66 | ||||||||
Address2: | SUITE 202 | ||||||||
City: | GLENDORA | ||||||||
State: | CA | ||||||||
PostalCode: | 917404335 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6269634467 | ||||||||
FaxNumber: | 6269639543 | ||||||||
Practice Location | |||||||||
Address1: | 415 W ROUTE 66 | ||||||||
Address2: | SUITE 202 | ||||||||
City: | GLENDORA | ||||||||
State: | CA | ||||||||
PostalCode: | 917404335 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6269634467 | ||||||||
FaxNumber: | 6269639543 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/17/2016 | ||||||||
LastUpdateDate: | 06/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CRUZ | ||||||||
AuthorizedOfficialFirstName: | CESAR | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 6269634467 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: | 06/17/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | A120136 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 00A120136 | 05 | CA |   | MEDICAID |