Healthcare Provider Details

I. General information

NPI: 1164696118
Provider Name (Legal Business Name): DR. MANUEL OMAR CRUZ-DIAZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2008
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

258 S CHICKASAW TRL STE 202
ORLANDO FL
32825-3501
US

IV. Provider business mailing address

258 S CHICKASAW TRL STE 202
ORLANDO FL
32825-3501
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-6865
  • Fax:
Mailing address:
  • Phone: 407-303-6865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberQ1584
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number18056
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberME117509
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: