Provider Demographics
NPI:1164451993
Name:CRUZAT-BLANCO, MERLITA C
Entity type:Individual
Prefix:
First Name:MERLITA
Middle Name:C
Last Name:CRUZAT-BLANCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MERLITA
Other - Middle Name:C
Other - Last Name:CRUZAT-BLANCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:500 NE MULTNOMAH ST FL 11
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2023
Mailing Address - Country:US
Mailing Address - Phone:800-813-2000
Mailing Address - Fax:
Practice Address - Street 1:7101 NE 137TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682-4933
Practice Address - Country:US
Practice Address - Phone:800-813-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088870207R00000X
CAC141148207R00000X
WAMD61392277207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088870Medicaid