Provider Demographics
NPI:1801801204
Name:CRUZ-GOVIN, MARLENE (OD)
Entity type:Individual
Prefix:DR
First Name:MARLENE
Middle Name:
Last Name:CRUZ-GOVIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4577 WESTON RD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33331-3141
Mailing Address - Country:US
Mailing Address - Phone:954-217-5070
Mailing Address - Fax:954-217-5080
Practice Address - Street 1:4577 WESTON RD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3141
Practice Address - Country:US
Practice Address - Phone:954-217-5070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2935152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20692OtherBCBS
FL620992100Medicaid
FL542128303OtherVSP
FLK7736Medicare ID - Type Unspecified
FLV05249Medicare UPIN