Provider Demographics
NPI:1164451993
Name:CRUZAT-BLANCO, MERLITA C
Entity Type:Individual
Prefix:
First Name:MERLITA
Middle Name:C
Last Name:CRUZAT-BLANCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MERLITA
Other - Middle Name:C
Other - Last Name:CRUZAT-BLANCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:7419 JUNEAU LN
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-0717
Mailing Address - Country:US
Mailing Address - Phone:773-503-9166
Mailing Address - Fax:
Practice Address - Street 1:9961 SIERRA AVE
Practice Address - Street 2:MOB2 KAISER MEDICAL CENTER
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335
Practice Address - Country:US
Practice Address - Phone:909-427-6914
Practice Address - Fax:909-427-4187
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088870207R00000X
CAC141148207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088870Medicaid