Healthcare Provider Details

I. General information

NPI: 1962926956
Provider Name (Legal Business Name): MARIO CRUZ OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2017
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 WELLINGTON AVE STE A
GRAND JUNCTION CO
81501-8180
US

IV. Provider business mailing address

PO BOX 200426
DALLAS TX
75320-0426
US

V. Phone/Fax

Practice location:
  • Phone: 970-256-0400
  • Fax: 970-256-9149
Mailing address:
  • Phone: 970-256-0400
  • Fax: 970-256-9149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT.0004207
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: