Basic Information
| Provider Information | |||||||||
| NPI: | 1710920426 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRUZ-MARTINEZ | ||||||||
| FirstName: | DRISDE | ||||||||
| MiddleName: | ISABEL | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 817 GRIFFIN AVE | ||||||||
| Address2: | |||||||||
| City: | EASTMAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310236718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4783741801 | ||||||||
| FaxNumber: | 4784484586 | ||||||||
| Practice Location | |||||||||
| Address1: | 817 GRIFFIN AVE | ||||||||
| Address2: | |||||||||
| City: | EASTMAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310236718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4783741801 | ||||||||
| FaxNumber: | 4784484586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 14520 | PR | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 23327CR | 01 | PR | TRIPLE S-HEALTH PROVIDER | OTHER |