Basic Information
| Provider Information | |||||||||
| NPI: | 1942283072 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRISTOBAL | ||||||||
| FirstName: | CARMELITA | ||||||||
| MiddleName: | FELICIANO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 Q ST | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958167058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167335701 | ||||||||
| FaxNumber: | 9168591671 | ||||||||
| Practice Location | |||||||||
| Address1: | 1820 41ST AVE | ||||||||
| Address2: | SUITE D | ||||||||
| City: | CAPITOLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950102516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314763000 | ||||||||
| FaxNumber: | 8314769009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 01/13/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 33358 | MN | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | C53347 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1942283072 | 05 | CA | MEDICAID | 370002482 | 05 | MN | MEDICAID |