Basic Information
| Provider Information | |||||||||
| NPI: | 1619170511 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRUZ | ||||||||
| FirstName: | MARCO | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 S J ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534266341 | ||||||||
| FaxNumber: | 2534266344 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 S J ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534266341 | ||||||||
| FaxNumber: | 2534266344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2007 | ||||||||
| LastUpdateDate: | 11/08/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD00047877 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0221361 | 01 | WA | L & I | OTHER | 8945495 | 01 | WA | CRIME VICTIMS | OTHER | P00477710 | 01 | WA | RAILROAD | OTHER | 8486185 | 05 | WA | MEDICAID |