Provider Demographics
NPI:1629162342
Name:CRUZZAVALA, JOSE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:
Last Name:CRUZZAVALA
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 1:600 18TH STREET
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101
Mailing Address - Country:US
Mailing Address - Phone:304-424-4760
Mailing Address - Fax:304-424-4761
Practice Address - Street 1:600 18TH STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101
Practice Address - Country:US
Practice Address - Phone:304-424-4760
Practice Address - Fax:304-424-4761
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV15479208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0129506000Medicaid
WV020045089OtherRAILROAD MEDICARE
WV020045089OtherRAILROAD MEDICARE
B42742Medicare UPIN