Provider Demographics
NPI:1891989380
Name:CRUZ, JORGE L (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:L
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 1:2104 GAUSE BLVD W
Mailing Address - Street 2:STE. A
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70460-4130
Mailing Address - Country:US
Mailing Address - Phone:985-643-4512
Mailing Address - Fax:985-643-4513
Practice Address - Street 1:2104 GAUSE BLVD W
Practice Address - Street 2:STE. A
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70460-4130
Practice Address - Country:US
Practice Address - Phone:985-643-4512
Practice Address - Fax:985-643-4513
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.201422208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1508012Medicaid
LA4N178Medicare PIN