Provider Demographics
NPI:1134190135
Name:CRUZ, ERNESTO R (MD)
Entity type:Individual
Prefix:DR
First Name:ERNESTO
Middle Name:R
Last Name:CRUZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ERNESTO
Other - Middle Name:R
Other - Last Name:CRUZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 61773
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85082-1773
Mailing Address - Country:US
Mailing Address - Phone:602-266-2200
Mailing Address - Fax:602-240-5862
Practice Address - Street 1:2632 N 20TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-1339
Practice Address - Country:US
Practice Address - Phone:602-266-2200
Practice Address - Fax:602-240-6177
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26508207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ429929Medicaid
AZ86-0338466OtherTIN
AZ429929Medicaid
AZ86-0338466OtherTIN
AZG47877Medicare UPIN