Healthcare Provider Details

I. General information

NPI: 1760536254
Provider Name (Legal Business Name): LUZ ELVA TRISTAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 08/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E BIRCH ST SUITE A
CALEXICO CA
92231-4351
US

IV. Provider business mailing address

401 E BIRCH ST SUITE A
CALEXICO CA
92231-2854
US

V. Phone/Fax

Practice location:
  • Phone: 760-768-5246
  • Fax: 760-768-2234
Mailing address:
  • Phone: 760-768-5246
  • Fax: 760-768-2234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA064252
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: