Healthcare Provider Details

I. General information

NPI: 1598068868
Provider Name (Legal Business Name): FIDEL SANTA-CRUZ M D A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2010
Last Update Date: 12/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 E FLORENCE AVE SUITE 3
HUNTINGTON PARK CA
90255-5848
US

IV. Provider business mailing address

3100 E FLORENCE AVE SUITE 3
HUNTINGTON PARK CA
90255-5848
US

V. Phone/Fax

Practice location:
  • Phone: 323-588-3125
  • Fax: 323-588-0919
Mailing address:
  • Phone: 323-588-3125
  • Fax: 323-588-0919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: FIDEL SANTA-CRUZ
Title or Position: OWNER
Credential: M D
Phone: 323-588-3125