Provider Demographics
NPI:1043301518
Name:CRUZ, JACOBO A (MD)
Entity Type:Individual
Prefix:
First Name:JACOBO
Middle Name:A
Last Name:CRUZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 BAYOU BLVD
Mailing Address - Street 2:SUITE 51
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2673
Mailing Address - Country:US
Mailing Address - Phone:850-484-7774
Mailing Address - Fax:850-484-8874
Practice Address - Street 1:4400 BAYOU BLVD
Practice Address - Street 2:SUITE 51
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2673
Practice Address - Country:US
Practice Address - Phone:850-484-7774
Practice Address - Fax:850-484-8874
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME489742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048405900Medicaid
FL02327ZMedicare PIN
FLD50454Medicare UPIN