Healthcare Provider Details

I. General information

NPI: 1154337053
Provider Name (Legal Business Name): DMITRI DE LA CRUZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 W I ST
LOS BANOS CA
93635-3479
US

IV. Provider business mailing address

311 W I ST
LOS BANOS CA
93635-3479
US

V. Phone/Fax

Practice location:
  • Phone: 209-826-2222
  • Fax: 209-826-2599
Mailing address:
  • Phone: 209-826-2222
  • Fax: 209-826-2599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG54368
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: