Provider Demographics
NPI:1609818152
Name:CRISTOBAL, NOLASCO (MD)
Entity Type:Individual
Prefix:
First Name:NOLASCO
Middle Name:
Last Name:CRISTOBAL
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 1:2550 WEST MAIN ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801
Mailing Address - Country:US
Mailing Address - Phone:626-457-6900
Mailing Address - Fax:626-457-5209
Practice Address - Street 1:1414 S GRAND AVE STE 380
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3072
Practice Address - Country:US
Practice Address - Phone:213-743-9000
Practice Address - Fax:213-743-9001
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48577208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A485770Medicaid
CAD33956Medicare UPIN
CA00A485770Medicaid