Provider Demographics
NPI:1063664696
Name:RUIZ, CAMILO A
Entity Type:Individual
Prefix:
First Name:CAMILO
Middle Name:A
Last Name:RUIZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1319 SE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-1809
Mailing Address - Country:US
Mailing Address - Phone:954-839-6987
Mailing Address - Fax:954-839-6923
Practice Address - Street 1:1319 SE 2ND AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-1809
Practice Address - Country:US
Practice Address - Phone:954-839-6987
Practice Address - Fax:954-839-6923
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-14
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10517207RS0012X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDB058WOtherPTAN
FL002898600Medicaid