Provider Demographics
NPI:1780812875
Name:CRUZ ALZATE, MARIO FERNANDO (PT)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:FERNANDO
Last Name:CRUZ ALZATE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 GALLERIA PKWY SE
Mailing Address - Street 2:SUIE 410
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3179
Mailing Address - Country:US
Mailing Address - Phone:770-953-6929
Mailing Address - Fax:770-953-6972
Practice Address - Street 1:354 NEWNAN CROSSING BYP
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2323
Practice Address - Country:US
Practice Address - Phone:770-460-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2012-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT009638225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I657010Medicare PIN