Provider Demographics
NPI:1639454671
Name:CRUZ, EDISON BAUTISTA (PT)
Entity Type:Individual
Prefix:
First Name:EDISON
Middle Name:BAUTISTA
Last Name:CRUZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2157
Mailing Address - Street 2:APT D29
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10949-7157
Mailing Address - Country:US
Mailing Address - Phone:718-644-4529
Mailing Address - Fax:718-684-2518
Practice Address - Street 1:2940 GRAND CONCOURSE
Practice Address - Street 2:SUITE 1A
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-2611
Practice Address - Country:US
Practice Address - Phone:718-684-2516
Practice Address - Fax:718-684-2518
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2016-10-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY033665-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY033665-1OtherLICENSE