Basic Information
| Provider Information | |||||||||
| NPI: | 1891989380 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRUZ | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2104 GAUSE BLVD W | ||||||||
| Address2: | STE. A | ||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704604130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856434512 | ||||||||
| FaxNumber: | 9856434513 | ||||||||
| Practice Location | |||||||||
| Address1: | 2104 GAUSE BLVD W | ||||||||
| Address2: | STE. A | ||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704604130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856434512 | ||||||||
| FaxNumber: | 9856434513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2007 | ||||||||
| LastUpdateDate: | 10/15/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | MD.201422 | LA | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1508012 | 05 | LA | MEDICAID |