Healthcare Provider Details

I. General information

NPI: 1154974574
Provider Name (Legal Business Name): MILTOM CRUZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2019
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 BROADWAY STE 500
OAKLAND CA
94612-2141
US

IV. Provider business mailing address

5674 STONERIDGE DR STE 207
PLEASANTON CA
94588-8592
US

V. Phone/Fax

Practice location:
  • Phone: 510-273-4200
  • Fax:
Mailing address:
  • Phone: 925-520-0005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number797510
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: