Healthcare Provider Details

I. General information

NPI: 1720072002
Provider Name (Legal Business Name): BRIAN CROSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 N TUSTIN AVE
SANTA ANA CA
92705-3502
US

IV. Provider business mailing address

PO BOX 10790
SANTA ANA CA
92711-0790
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-3515
  • Fax: 714-953-4259
Mailing address:
  • Phone: 949-553-0010
  • Fax: 949-553-0098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG40254
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: