Provider Demographics
NPI:1043598287
Name:CRUZ BENITEZ, JORGE FERNANDO (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:FERNANDO
Last Name:CRUZ BENITEZ
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 1:5 CONSTITUTION PLZ
Mailing Address - Street 2:APARTMENT 514, SPECTRA APARTMENTS
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06103-1818
Mailing Address - Country:US
Mailing Address - Phone:409-996-1359
Mailing Address - Fax:
Practice Address - Street 1:9600 DATAPOINT DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-2028
Practice Address - Country:US
Practice Address - Phone:210-892-3700
Practice Address - Fax:210-614-4636
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR4206207ZP0102X
PAMD454860390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology