Provider Demographics
NPI:1164522546
Name:DE LA CRUZ, MANUEL R (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:R
Last Name:DE LA CRUZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 W EATON AVE
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-3422
Mailing Address - Country:US
Mailing Address - Phone:209-833-2228
Mailing Address - Fax:
Practice Address - Street 1:518 W EATON AVE
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3422
Practice Address - Country:US
Practice Address - Phone:209-833-2228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50064208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ01387ZOtherBLUE SHIELD GROUP ID #