Provider Demographics
NPI:1609850502
Name:CRUZ VEGERANO, ELISA (MD)
Entity Type:Individual
Prefix:DR
First Name:ELISA
Middle Name:
Last Name:CRUZ VEGERANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:220 PRESIDENTS CUP WAY
Mailing Address - Street 2:UNIT 201
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3728
Mailing Address - Country:US
Mailing Address - Phone:787-667-0175
Mailing Address - Fax:787-667-0175
Practice Address - Street 1:195 SOUTH PARK BLVD
Practice Address - Street 2:
Practice Address - City:ST. AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086
Practice Address - Country:US
Practice Address - Phone:904-829-0814
Practice Address - Fax:904-829-0814
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12991207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine