Provider Demographics
NPI:1639733207
Name:CRUZ GARCIA, ROBERTO LUIS (MD)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:LUIS
Last Name:CRUZ GARCIA
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 1:2577 GUNN HWY APT 217
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-2535
Mailing Address - Country:US
Mailing Address - Phone:786-603-1877
Mailing Address - Fax:
Practice Address - Street 1:127 RIDGE CENTER DR
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-6401
Practice Address - Country:US
Practice Address - Phone:863-421-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2021-02-15
Deactivation Date:2020-10-17
Deactivation Code:
Reactivation Date:2020-10-28
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLACN1282208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program