Provider Demographics
NPI:1891007746
Name:VIVAR CRUZ, PEDRO WILFRIDO (MD)
Entity Type:Individual
Prefix:
First Name:PEDRO
Middle Name:WILFRIDO
Last Name:VIVAR 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:PO BOX 8035
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-0035
Mailing Address - Country:US
Mailing Address - Phone:316-689-9135
Mailing Address - Fax:316-689-9667
Practice Address - Street 1:848 N ST FRANCIS ST STE 3949
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3859
Practice Address - Country:US
Practice Address - Phone:316-268-8500
Practice Address - Fax:316-291-7993
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-378022084N0400X
IL0361358752084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201113500AMedicaid