Healthcare Provider Details

I. General information

NPI: 1063603553
Provider Name (Legal Business Name): ANTONIO P. CRUZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1287 N MAIN ST
PROVIDENCE RI
02904-1856
US

IV. Provider business mailing address

1287 N MAIN ST
PROVIDENCE RI
02904-1856
US

V. Phone/Fax

Practice location:
  • Phone: 401-272-2724
  • Fax: 401-272-2784
Mailing address:
  • Phone: 401-272-2724
  • Fax: 401-272-2784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number246717
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberMD13344
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD13344
License Number StateRI
# 4
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number246717
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: