Healthcare Provider Details

I. General information

NPI: 1164522546
Provider Name (Legal Business Name): MANUEL R DE LA CRUZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 W EATON AVE
TRACY CA
95376-3422
US

IV. Provider business mailing address

518 W EATON AVE
TRACY CA
95376-3422
US

V. Phone/Fax

Practice location:
  • Phone: 209-833-2228
  • Fax:
Mailing address:
  • Phone: 209-833-2228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA50064
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: