Provider Demographics
NPI:1477644979
Name:CRUZ-LEAL, WILSON JAVIER (MD)
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:JAVIER
Last Name:CRUZ-LEAL
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:PO BOX 11449
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4005
Mailing Address - Country:US
Mailing Address - Phone:479-709-1924
Mailing Address - Fax:479-709-7499
Practice Address - Street 1:1480 W CENTER ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:AR
Practice Address - Zip Code:72936-3449
Practice Address - Country:US
Practice Address - Phone:479-996-5585
Practice Address - Fax:479-996-5386
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA106916207Q00000X
ARE5921207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC71030FMedicaid
CAW1508CMedicare PIN
CAW1508AMedicare PIN
CA551907Medicare Oscar/Certification
CA551983Medicare Oscar/Certification
CA551978Medicare Oscar/Certification
CAFHC71030FMedicaid