Healthcare Provider Details

I. General information

NPI: 1740499532
Provider Name (Legal Business Name): MARINELY CRUZ-AMY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 04/29/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 IMAGE WAY
ORANGE CITY FL
32763-8399
US

IV. Provider business mailing address

PO BOX 102222 ATTN CREDENTIALING DEPT
ATLANTA GA
30368-2222
US

V. Phone/Fax

Practice location:
  • Phone: 386-774-7411
  • Fax: 386-774-7412
Mailing address:
  • Phone: 239-274-8200
  • Fax: 239-278-3350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberME111183
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: