Basic Information
| Provider Information | |||||||||
| NPI: | 1487121232 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRUZ | ||||||||
| FirstName: | MELANI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | CRUZ | ||||||||
| OtherFirstName: | MELANIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 5712236780 | ||||||||
| Practice Location | |||||||||
| Address1: | 5426 JEFFERSON DAVIS HWY | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224072616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5408912020 | ||||||||
| FaxNumber: | 5408985005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2018 | ||||||||
| LastUpdateDate: | 08/10/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 60906074 | WA | N | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 152W00000X | 0618003006 | VA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.