Healthcare Provider Details

I. General information

NPI: 1033134770
Provider Name (Legal Business Name): CRESENCIA D BANZUELA M.D. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 E ONTARIO AVE SUITE 204
CORONA CA
92879-3506
US

IV. Provider business mailing address

PO BOX 6038
CORONA CA
92878-6038
US

V. Phone/Fax

Practice location:
  • Phone: 951-272-6595
  • Fax:
Mailing address:
  • Phone: 951-272-3872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: CRESENCIA BANZUELA
Title or Position: DIRECTOR
Credential: M.D.
Phone: 951-272-6595