Provider Demographics
NPI:1972186591
Name:CRUZ, BLANCA N (E8Z8T6M5)
Entity Type:Individual
Prefix:
First Name:BLANCA
Middle Name:N
Last Name:CRUZ
Suffix:
Gender:F
Credentials:E8Z8T6M5
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10429 INTERNATIONAL BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94603-3221
Mailing Address - Country:US
Mailing Address - Phone:510-777-8448
Mailing Address - Fax:
Practice Address - Street 1:10429 INTERNATIONAL BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94603-3221
Practice Address - Country:US
Practice Address - Phone:510-777-8448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-02
Last Update Date:2021-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF7106482Medicaid