Provider Demographics
NPI:1588620207
Name:CRUZ, RAFAEL F (MD)
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:F
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 1:1010 W HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47129-2537
Mailing Address - Country:US
Mailing Address - Phone:859-468-5065
Mailing Address - Fax:502-272-5114
Practice Address - Street 1:405 E COURT AVE STE 102
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3474
Practice Address - Country:US
Practice Address - Phone:812-913-4416
Practice Address - Fax:812-213-8409
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37305207PE0004X
WA60939143207PE0004X
IN01046661A207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00319187OtherRAILROAD MEDICARE
INP00319187OtherRAILROAD MEDICARE
KY1361974Medicare PIN
IN196290EEMedicare PIN
IN200474910Medicaid