Provider Demographics
NPI:1699192765
Name:FERNANDEZ-CRUZ, CARLOS J (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:J
Last Name:FERNANDEZ-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 1:400 AVE FD ROOSEVELT
Mailing Address - Street 2:STE 408
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918-2163
Mailing Address - Country:US
Mailing Address - Phone:787-765-1919
Mailing Address - Fax:787-751-8739
Practice Address - Street 1:1801 AVE PONCE DE LEON STE 409-410
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909-1900
Practice Address - Country:US
Practice Address - Phone:939-338-0793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-26
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR19622207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR038174400Medicaid