Provider Demographics
NPI:1992012595
Name:CERVANTES- GROS, ELIDA LIBRADA (DPM)
Entity Type:Individual
Prefix:
First Name:ELIDA
Middle Name:LIBRADA
Last Name:CERVANTES- GROS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:ELIDA
Other - Middle Name:LIBRADA
Other - Last Name:CERVANTES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:10470 OLD PLACERVILLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:2725 CAPITOL AVE DEPT 302
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816
Practice Address - Country:US
Practice Address - Phone:916-262-9464
Practice Address - Fax:916-262-9468
Is Sole Proprietor?:No
Enumeration Date:2010-09-03
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1952213E00000X
CAE5599213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1952OtherSTATE LICENSE