Provider Demographics
NPI:1720746662
Name:CRUIKSHANK, JACK (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:CRUIKSHANK
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 1:1111 E PALM CANYON DR UNIT 120
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92264-9199
Mailing Address - Country:US
Mailing Address - Phone:403-835-9023
Mailing Address - Fax:
Practice Address - Street 1:MORONGO BASIN COMMUNITY HEALTH CENTER
Practice Address - Street 2:58375 29 PALMS HWY
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284
Practice Address - Country:US
Practice Address - Phone:760-820-9229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC174737207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine