1811050602 NPI number — DR. CRUZ MARTINA FANA-SOUCHET MD

Table of content: DR. CRUZ MARTINA FANA-SOUCHET MD (NPI 1811050602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811050602 NPI number — DR. CRUZ MARTINA FANA-SOUCHET MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FANA-SOUCHET
Provider First Name:
CRUZ
Provider Middle Name:
MARTINA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FANA
Provider Other First Name:
CRUZ
Provider Other Middle Name:
MARTINA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1811050602
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 PATRICIA AVE STE B
Provider Second Line Business Mailing Address:
AMA MEDICAL GROUP
Provider Business Mailing Address City Name:
DUNEDIN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34698-8100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-331-8740
Provider Business Mailing Address Fax Number:
727-331-8744

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 PATRICIA AVE STE B
Provider Second Line Business Practice Location Address:
AMA MEDICAL GROUP
Provider Business Practice Location Address City Name:
DUNEDIN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34698-8100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-331-8740
Provider Business Practice Location Address Fax Number:
727-331-8744
Provider Enumeration Date:
12/19/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  ME96750 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: ME96750 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000875300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".