Provider Demographics
NPI:1649614397
Name:CRUZ CRUZ, AMANDA E (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:E
Last Name:CRUZ CRUZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 BAPTIST WAY
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-7600
Mailing Address - Country:US
Mailing Address - Phone:786-243-8073
Mailing Address - Fax:786-576-0471
Practice Address - Street 1:975 BAPTIST WAY
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-7600
Practice Address - Country:US
Practice Address - Phone:786-243-8073
Practice Address - Fax:786-576-0471
Is Sole Proprietor?:No
Enumeration Date:2013-04-24
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA300915207R00000X, 208M00000X
390200000X
FLME154751207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08126845Medicaid
LA2334107Medicaid
LA2334107Medicaid