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General NPI Number Information
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NPI Number | 1164710786
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Entity Type | Individual
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Provider Name | MARK MANLUTAC CRUZ M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/17/2011
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Last Update Date | 08/26/2020
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Provider Practice Location Address
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Address Line | 620 JOHN PAUL JONES CIR
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City | PORTSMOUTH
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State | VA
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Zip | 23708-2197
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Country | US
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Telephone | 757-953-3500
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Fax |
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Provider Business Mailing Address
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Address Line | 1725 FISHERS CV
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City | CHESAPEAKE
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State | VA
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Zip | 23321-1992
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Country | US
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Telephone | 757-477-6124
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | T63028072
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 207RE0101X
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Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
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License Number | 0101252328
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License Number State | VA
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