Provider Demographics
NPI:1376938183
Name:CRUZ, JASMINE
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:CRUZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 VIA D ESTE APT 1506
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33445-3978
Mailing Address - Country:US
Mailing Address - Phone:407-535-5139
Mailing Address - Fax:
Practice Address - Street 1:7730 W BOYNTON BEACH BLVD STE 7
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-6155
Practice Address - Country:US
Practice Address - Phone:561-369-2199
Practice Address - Fax:561-935-1582
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3913213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025110800Medicaid