Provider Demographics
NPI:1760057657
Name:CRUZ, MARK LUKE DIZON (OTL)
Entity Type:Individual
Prefix:MR
First Name:MARK LUKE
Middle Name:DIZON
Last Name:CRUZ
Suffix:
Gender:M
Credentials:OTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 ELM SPRING CT
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75002-6393
Mailing Address - Country:US
Mailing Address - Phone:972-832-1352
Mailing Address - Fax:
Practice Address - Street 1:4510 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75069-1650
Practice Address - Country:US
Practice Address - Phone:972-540-8081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111909225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist