Healthcare Provider Details

I. General information

NPI: 1083639710
Provider Name (Legal Business Name): CRESENCIA DELEON BANZUELA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 E ONTARIO AVE SUITE 204
CORONA CA
92879-3514
US

IV. Provider business mailing address

PO BOX 6038
CORONA CA
92878-6038
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA53873
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: