Healthcare Provider Details

I. General information

NPI: 1366239451
Provider Name (Legal Business Name): SHANTALLE LORILYNN DIAZ CRUZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2025
Last Update Date: 04/22/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UC DAVIS HEALTH DEPARTMENT OF PEDIATRICS 2516 STOCKTON BOULEVARD
SACRAMENTO CA
95817
US

IV. Provider business mailing address

718 HOBART AVENUE
ATLANTIC CITY NJ
08401
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-3665
  • Fax: 916-734-0342
Mailing address:
  • Phone: 829-904-8858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: