Provider Demographics
NPI:1073688628
Name:CRISTOBAL, MARITA G
Entity type:Individual
Prefix:
First Name:MARITA
Middle Name:G
Last Name:CRISTOBAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 E LIVE OAK AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-5617
Mailing Address - Country:US
Mailing Address - Phone:626-821-5858
Mailing Address - Fax:626-821-0858
Practice Address - Street 1:330 E LIVE OAK AVE
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-5617
Practice Address - Country:US
Practice Address - Phone:626-821-5858
Practice Address - Fax:626-821-0858
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA361482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA36148AMedicare PIN