Provider Demographics
NPI:1841979937
Name:CRUZ, MARISSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:CRUZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13904 N DALE MABRY HWY STE 200
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-2446
Mailing Address - Country:US
Mailing Address - Phone:813-908-2020
Mailing Address - Fax:813-908-2133
Practice Address - Street 1:2521 NW 41ST ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-6630
Practice Address - Country:US
Practice Address - Phone:352-377-7733
Practice Address - Fax:352-377-9577
Is Sole Proprietor?:No
Enumeration Date:2023-07-14
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6295152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist