Provider Demographics
NPI:1619596426
Name:DE LA CRUZ MAYHUA, JUAN CARLOS
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:DE LA CRUZ MAYHUA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 JUNIPERO AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-8760
Mailing Address - Country:US
Mailing Address - Phone:310-590-5841
Mailing Address - Fax:
Practice Address - Street 1:2107 JUNIPERO AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93619-8760
Practice Address - Country:US
Practice Address - Phone:310-590-5841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-11
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA183754207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine