Provider Demographics
NPI:1356659502
Name:NIDSA I MARTIR CRUZ MD PA
Entity Type:Organization
Organization Name:NIDSA I MARTIR CRUZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NIDSA
Authorized Official - Middle Name:I
Authorized Official - Last Name:MARTIR CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-323-0888
Mailing Address - Street 1:PO BOX 490918
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34749-0918
Mailing Address - Country:US
Mailing Address - Phone:352-323-0888
Mailing Address - Fax:352-323-9103
Practice Address - Street 1:4700 VIA DEL MEDICO
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-9723
Practice Address - Country:US
Practice Address - Phone:352-323-0888
Practice Address - Fax:352-323-9103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00631642084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371597300Medicaid
FL18153Medicare PIN
FL371597300Medicaid