Provider Demographics
NPI:1265452338
Name:CRUZ, CARLOS ALBERTO (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ALBERTO
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 1:10000 MARSHALL POND RD
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-3709
Mailing Address - Country:US
Mailing Address - Phone:703-323-5292
Mailing Address - Fax:
Practice Address - Street 1:1707 OSAGE ST
Practice Address - Street 2:SUITE 303
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-2607
Practice Address - Country:US
Practice Address - Phone:703-824-0970
Practice Address - Fax:703-824-0972
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233315208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics