Provider Demographics
NPI:1619918851
Name:CRUZ, CARLOS (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
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 1:9231 HIDDEN MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-7423
Mailing Address - Country:US
Mailing Address - Phone:504-913-2789
Mailing Address - Fax:
Practice Address - Street 1:9231 HIDDEN MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-7423
Practice Address - Country:US
Practice Address - Phone:504-913-2789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13866R207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAA127OtherCHAMPUS
LA561696907COtherBLUE CROSS
LA1572331Medicaid
LAH48117Medicare UPIN
LA1572331Medicaid