Basic Information
| Provider Information | |||||||||
| NPI: | 1891007746 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VIVAR CRUZ | ||||||||
| FirstName: | PEDRO | ||||||||
| MiddleName: | WILFRIDO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8035 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672080035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166899135 | ||||||||
| FaxNumber: | 3166899667 | ||||||||
| Practice Location | |||||||||
| Address1: | 848 N ST FRANCIS ST STE 3949 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672143859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162688500 | ||||||||
| FaxNumber: | 3162917993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2010 | ||||||||
| LastUpdateDate: | 10/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 04-37802 | KS | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 201113500A | 05 | KS | MEDICAID |