Basic Information
| Provider Information | |||||||||
| NPI: | 1588868616 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATOS-CRUZ | ||||||||
| FirstName: | MARIO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 432 | ||||||||
| Address2: | |||||||||
| City: | PIKEVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 415020432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062186402 | ||||||||
| FaxNumber: | 6062187502 | ||||||||
| Practice Location | |||||||||
| Address1: | 830 W HIGH ST STE 207 | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458013975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199964011 | ||||||||
| FaxNumber: | 4199964012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 35065706 | OH | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 0065177 | 05 | OH | MEDICAID | 20010800A | 05 | IN | MEDICAID |