Provider Demographics
NPI:1962628677
Name:CRUZ, MARIO JR (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:CRUZ
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:1233 LOCUST ST FL 3
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5400
Mailing Address - Country:US
Mailing Address - Phone:215-985-4448
Mailing Address - Fax:215-732-1145
Practice Address - Street 1:1207 CHESTNUT ST FL 5
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4131
Practice Address - Country:US
Practice Address - Phone:215-525-8600
Practice Address - Fax:215-564-8606
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2018-03-17
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Provider Licenses
StateLicense IDTaxonomies
PAMD432064208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1020627490005Medicaid