Healthcare Provider Details

I. General information

NPI: 1407383094
Provider Name (Legal Business Name): JOSE MARCO JULIAN JA RUIZ DE LUZURIAGA MENDEZONA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2017
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 W UNIVERSITY AVE STE 401
MUNCIE IN
47303-3433
US

IV. Provider business mailing address

2401 W UNIVERSITY AVE
MUNCIE IN
47303-3428
US

V. Phone/Fax

Practice location:
  • Phone: 765-747-4306
  • Fax:
Mailing address:
  • Phone: 765-741-1515
  • Fax: 765-751-5087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01084065A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01084065A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: