Provider Demographics
NPI:1578545729
Name:CRUZ, RENE FULGENCIO (MD)
Entity Type:Individual
Prefix:MR
First Name:RENE
Middle Name:FULGENCIO
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 1:424 LAKE HOWELL RD
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5907
Mailing Address - Country:US
Mailing Address - Phone:407-644-6401
Mailing Address - Fax:407-644-8611
Practice Address - Street 1:424 LAKE HOWELL RD
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5907
Practice Address - Country:US
Practice Address - Phone:407-644-6401
Practice Address - Fax:407-644-8611
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0068986207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256125500Medicaid
FLBC4589632OtherDEA
FLBC4589632OtherDEA
G14285Medicare UPIN