Basic Information
| Provider Information | |||||||||
| NPI: | 1679505259 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRUZ | ||||||||
| FirstName: | CARLOS | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1611 NW 12TH AVE | ||||||||
| Address2: | BOX 016960 (M851) | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052436358 | ||||||||
| FaxNumber: | 3052438470 | ||||||||
| Practice Location | |||||||||
| Address1: | 1611 NW 12TH AVE | ||||||||
| Address2: | BOX 016960 (M851) | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052436358 | ||||||||
| FaxNumber: | 3052438470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 03/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | C166627 | CA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | ME91715 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 2728907-00 | 05 | FL | MEDICAID |