=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356659502
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NIDSA I MARTIR CRUZ MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2010
-----------------------------------------------------
Last Update Date | 06/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26540 ACE AVE STE H103
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34748-8279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-323-0888
-----------------------------------------------------
Fax | 352-323-9103
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 490918
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34749-0918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-323-0888
-----------------------------------------------------
Fax | 352-323-9103
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. NIDSA I MARTIR CRUZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 352-323-0888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | ME0063164
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------