Healthcare Provider Details

I. General information

NPI: 1346283785
Provider Name (Legal Business Name): ELIZARDO MATOS CRUZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 CALLE 44 SE RPTO METROPOLITANO
SAN JUAN PR
00921-2719
US

IV. Provider business mailing address

PO BOX 364388
SAN JUAN PR
00936-4388
US

V. Phone/Fax

Practice location:
  • Phone: 787-281-6559
  • Fax: 787-281-6142
Mailing address:
  • Phone: 787-281-6559
  • Fax: 787-281-6145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number9058
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: