Provider Demographics
NPI: | 1619097730 |
---|---|
Name: | RUIZ, VICTOR (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | VICTOR |
Middle Name: | |
Last Name: | RUIZ |
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: | 1166 K ST |
Mailing Address - Street 2: | |
Mailing Address - City: | BRAWLEY |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92227-2737 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 760-344-9951 |
Mailing Address - Fax: | 760-344-1629 |
Practice Address - Street 1: | 1023 E FLORIDA AVE |
Practice Address - Street 2: | |
Practice Address - City: | HEMET |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92543-4510 |
Practice Address - Country: | US |
Practice Address - Phone: | 951-599-8403 |
Practice Address - Fax: | 951-766-0930 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-03-30 |
Last Update Date: | 2022-07-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MA | 245156 | 207Q00000X, 207Q00000X |
390200000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | |
No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MA | 110086863A | Medicaid | |
MA | J47858 | Other | BLUE CROSS BLUE SHIELD |
MA | AA298325 | Other | HARVARD PILGRIM |