Healthcare Provider Details

I. General information

NPI: 1932266103
Provider Name (Legal Business Name): MARK TOLENTINO DELA CRUZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78120 WILDCAT DR
PALM DESERT CA
92211-1140
US

IV. Provider business mailing address

78120 WILDCAT DR
PALM DESERT CA
92211-1140
US

V. Phone/Fax

Practice location:
  • Phone: 760-340-2682
  • Fax: 760-773-9695
Mailing address:
  • Phone: 760-340-2682
  • Fax: 760-773-9695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberA93803
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberA93803
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA93803
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: