Healthcare Provider Details

I. General information

NPI: 1225232762
Provider Name (Legal Business Name): OLIVIA T. CRUZ, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

277 W CHALAN SANTO PAPA
HAGATNA GU
96910-5115
US

IV. Provider business mailing address

PO BOX DY
HAGATNA GU
96932-7502
US

V. Phone/Fax

Practice location:
  • Phone: 671-479-6363
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM10058
License Number StateGU

VIII. Authorized Official

Name: CARLA T HADDOCK
Title or Position: OFFICE MANAGER
Credential:
Phone: 671-479-6363