Provider Demographics
NPI:1184359804
Name:SAMOT CRUZ, OMAR ANTONIO SR
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:ANTONIO
Last Name:SAMOT CRUZ
Suffix:SR
Gender:M
Credentials:
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 2537
Mailing Address - Street 2:
Mailing Address - City:ISABELA
Mailing Address - State:PR
Mailing Address - Zip Code:00662-9537
Mailing Address - Country:US
Mailing Address - Phone:939-717-1653
Mailing Address - Fax:
Practice Address - Street 1:121 RUTA 474
Practice Address - Street 2:
Practice Address - City:ISABELA
Practice Address - State:PR
Practice Address - Zip Code:00662-4023
Practice Address - Country:US
Practice Address - Phone:939-323-0563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2024-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7453103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling