Provider Demographics
NPI:1578747457
Name:DELACRUZ, EMMANUEL
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:
Last Name:DELACRUZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546 W COMPTON BLVD
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90220-3011
Mailing Address - Country:US
Mailing Address - Phone:310-885-2106
Mailing Address - Fax:
Practice Address - Street 1:546 W COMPTON BLVD
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90220-3011
Practice Address - Country:US
Practice Address - Phone:310-885-2106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC382722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW61641Medicare PIN