Provider Demographics
NPI:1669824389
Name:CRUZ, GISELE PORTES
Entity Type:Individual
Prefix:
First Name:GISELE
Middle Name:PORTES
Last Name:CRUZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 RIVER VIEW PL
Mailing Address - Street 2:
Mailing Address - City:NORTH WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02191-2218
Mailing Address - Country:US
Mailing Address - Phone:174-620-6176
Mailing Address - Fax:
Practice Address - Street 1:18 RIVER VIEW PL
Practice Address - Street 2:
Practice Address - City:NORTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02191-2218
Practice Address - Country:US
Practice Address - Phone:617-462-0617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-06
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2820532085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology