Provider Demographics
NPI:1164696894
Name:CRUZ, GLEN GOMEZ (PT)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:GOMEZ
Last Name:CRUZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 GAINESWAY CT
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-1738
Mailing Address - Country:US
Mailing Address - Phone:678-468-7703
Mailing Address - Fax:770-497-6405
Practice Address - Street 1:3100 CLUB DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-2591
Practice Address - Country:US
Practice Address - Phone:770-923-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008454225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT008454OtherSTATE OF GEORGIA PT BOARD