Basic Information
| Provider Information | |||||||||
| NPI: | 1609282722 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRUZ REPOLLET | ||||||||
| FirstName: | IVAN | ||||||||
| MiddleName: | ARIEL | ||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4340 W HILLSBOROUGH AVE STE 210 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336145522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8134258970 | ||||||||
| FaxNumber: | 8134258925 | ||||||||
| Practice Location | |||||||||
| Address1: | 4340 W HILLSBOROUGH AVE STE 210 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336145522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8134258970 | ||||||||
| FaxNumber: | 8134258925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2014 | ||||||||
| LastUpdateDate: | 02/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME153523 | FL | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 0441252 | KS | N | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | 19,231 | PR | N | Allopathic & Osteopathic Physicians | General Practice | 390200000X | 13,569-I | PR | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208D00000X | ME153523 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.