Provider Demographics
NPI:1922071448
Name:VITO CRUZ, MARISSA GALVEZ (MD)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:GALVEZ
Last Name:VITO CRUZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARISSA
Other - Middle Name:G
Other - Last Name:VITOCRUZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:16000 JOHNSTON MEMORIAL DR
Practice Address - Street 2:FOURTH FLOOR
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211-7664
Practice Address - Country:US
Practice Address - Phone:276-258-4050
Practice Address - Fax:276-258-4056
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101221333207P00000X, 208M00000X, 207Q00000X
TN48344207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1922071448Medicaid
TN1527723Medicaid
VAP01245198OtherRAILROAD MEDICARE
TN103I088932Medicare PIN
TN103I082890Medicare PIN
VAP01245198OtherRAILROAD MEDICARE
VA1922071448Medicaid
VAVV4041BMedicare PIN
TN103I080288Medicare PIN
VAVV4041DMedicare PIN
VA015932W82Medicare PIN
VAV V4041AMedicare PIN