Provider Demographics
NPI:1699302455
Name:CRUZ, MANUEL ALEJANDRO (MD)
Entity type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:ALEJANDRO
Last Name:CRUZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MANUEL
Other - Middle Name:ALEJANDRO
Other - Last Name:CRUZ HERMOSILLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:815 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-6123
Mailing Address - Country:US
Mailing Address - Phone:323-728-3955
Mailing Address - Fax:
Practice Address - Street 1:815 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-6123
Practice Address - Country:US
Practice Address - Phone:323-728-3955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CAA181120207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program