Provider Demographics
NPI:1164696118
Name:CRUZ-DIAZ, MANUEL OMAR
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:OMAR
Last Name:CRUZ-DIAZ
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 1:258 S CHICKASAW TRL STE 202
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-3501
Mailing Address - Country:US
Mailing Address - Phone:407-303-6865
Mailing Address - Fax:
Practice Address - Street 1:258 S CHICKASAW TRL STE 202
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-3501
Practice Address - Country:US
Practice Address - Phone:407-303-6865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-21
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ15842088P0231X
PR18056208D00000X
FLME1175092088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice