Provider Demographics
NPI:1275689085
Name:CRUZ, ILDEFONSO (MD)
Entity Type:Individual
Prefix:DR
First Name:ILDEFONSO
Middle Name:
Last Name:CRUZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ILDEFONSO
Other - Middle Name:
Other - Last Name:CRUZ-PORTALATIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1646 E HERNDON AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3380
Mailing Address - Country:US
Mailing Address - Phone:559-449-7300
Mailing Address - Fax:559-449-7311
Practice Address - Street 1:1646 E HERNDON AVE STE 102
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3380
Practice Address - Country:US
Practice Address - Phone:559-449-7300
Practice Address - Fax:559-449-7311
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG28469207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG28469OtherLICENSE
AC6458029OtherDEA
C04168Medicare UPIN