1861622060 NPI number — DR. VICTOR DAMASO CRUZ MD

Table of content: (NPI 1003302423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861622060 NPI number — DR. VICTOR DAMASO CRUZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRUZ
Provider First Name:
VICTOR
Provider Middle Name:
DAMASO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CRUZ-HERRERO
Provider Other First Name:
VICTOR
Provider Other Middle Name:
DAMASO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1861622060
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1190 E WASHINGTON ST UNIT 113
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33602-3708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-808-3142
Provider Business Mailing Address Fax Number:
813-436-8927

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 N 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33602-3661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-397-3632
Provider Business Practice Location Address Fax Number:
813-397-3601
Provider Enumeration Date:
07/22/2009

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: 208D00000X , with the licence number:  12476 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: ME117105 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208M00000X , with the licence number: ME117105 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 101488400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".