Provider Demographics
NPI:1851310239
Name:CRUZ, RAFAEL (MD)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
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 1:1700 DIVIDEND DR
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1572
Mailing Address - Country:US
Mailing Address - Phone:574-722-7407
Mailing Address - Fax:574-735-0429
Practice Address - Street 1:1700 DIVIDEND DR
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1572
Practice Address - Country:US
Practice Address - Phone:574-722-7407
Practice Address - Fax:574-735-0429
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046661A207Q00000X
PAMD073155L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1025449080001Medicaid
PAMD-073155-LOtherMEDICAL LICENSE
NV10380OtherMEDICAL LICENSE
NY221853-1OtherMEDICAL LICENSE
NV003102887Medicaid
NVCS11551OtherPHARMACY CERTIFICATE
NVCS11551OtherPHARMACY CERTIFICATE
PA1025449080001Medicaid
NV003102887Medicaid