MEDICARE: CRESENCIA D BANZUELA M.D. INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1033134770
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRESENCIA D BANZUELA M.D. INC

Provider Business Mailing Address
First Line	:	PO BOX 6038
Second Line	:
City	:	CORONA
State	:	CA
Zip	:	92878-6038
Country	:	US
Telephone Number	:	951-272-3872
Fax Number	:

Provider Business Practice Location Address
First Line	:	260 E ONTARIO AVE
Second Line	:	SUITE 204
City	:	CORONA
State	:	CA
Zip	:	92879-3506
Country	:	US
Telephone Number	:	951-272-6595
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	CRESENCIA BANZUELA
Credential	:	M.D.
Telephone Number	:	951-272-6595

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	08/20/2008

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