Provider Demographics
NPI:1609388891
Name:CRUZ PEREZ, RAYMOND MARTIN
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:MARTIN
Last Name:CRUZ PEREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 E STELLA ST APT 2
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-2812
Mailing Address - Country:US
Mailing Address - Phone:267-515-3875
Mailing Address - Fax:
Practice Address - Street 1:2022 E ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-3817
Practice Address - Country:US
Practice Address - Phone:215-356-7247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-29
Last Update Date:2017-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA25512474172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA$$$$$$$$$Medicaid