=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457687766
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID SAMUEL SIEGA CRUZ P.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2009
-----------------------------------------------------
Last Update Date | 10/20/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3770 63RD ST APT. 2-B
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377-2634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-379-0240
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3770 63RD ST APT. 2-B
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377-2634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-379-0240
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 028916
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------