Provider Demographics
NPI:1811050602
Name:FANA-SOUCHET, CRUZ MARTINA (MD)
Entity type:Individual
Prefix:DR
First Name:CRUZ
Middle Name:MARTINA
Last Name:FANA-SOUCHET
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CRUZ
Other - Middle Name:MARTINA
Other - Last Name:FANA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:125 PATRICIA AVE STE B
Mailing Address - Street 2:AMA MEDICAL GROUP
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-8100
Mailing Address - Country:US
Mailing Address - Phone:727-331-8740
Mailing Address - Fax:727-331-8744
Practice Address - Street 1:125 PATRICIA AVE STE B
Practice Address - Street 2:AMA MEDICAL GROUP
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-8100
Practice Address - Country:US
Practice Address - Phone:727-331-8740
Practice Address - Fax:727-331-8744
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96750207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000875300Medicaid
FLAG509YMedicare PIN