Provider Demographics
NPI:1720072002
Name:CROSS, BRIAN (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:CROSS
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:PO BOX 10790
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92711-0790
Mailing Address - Country:US
Mailing Address - Phone:949-553-0010
Mailing Address - Fax:949-553-0098
Practice Address - Street 1:1001 N TUSTIN AVE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3502
Practice Address - Country:US
Practice Address - Phone:714-953-3515
Practice Address - Fax:714-953-4259
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40254174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G402541Medicaid
G40254Medicare ID - Type Unspecified
CAA91270Medicare UPIN