Provider Demographics
NPI:1831647205
Name:CRUZ, MARCELO ROCHA DE SOUSA (MD)
Entity Type:Individual
Prefix:MR
First Name:MARCELO
Middle Name:ROCHA DE SOUSA
Last Name: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 1:233 EAST SUPERIOR STREET, SUITE 01-023
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611
Mailing Address - Country:US
Mailing Address - Phone:312-472-1234
Mailing Address - Fax:312-472-0564
Practice Address - Street 1:233 EAST SUPERIOR STREET
Practice Address - Street 2:1ST FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-472-1234
Practice Address - Fax:312-472-0574
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125069681207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1831647205OtherNPI