Provider Demographics
NPI:1164710786
Name:CRUZ, MARK MANLUTAC (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:MANLUTAC
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 1:1725 FISHERS CV
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-1992
Mailing Address - Country:US
Mailing Address - Phone:757-477-6124
Mailing Address - Fax:
Practice Address - Street 1:620 JOHN PAUL JONES CIR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708-2197
Practice Address - Country:US
Practice Address - Phone:757-953-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-17
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT63028072207R00000X
VA0101252328207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine