Provider Demographics
NPI:1134089782
Name:LEAL-CRUZ, JAVIER CESAR
Entity type:Individual
Prefix:
First Name:JAVIER
Middle Name:CESAR
Last Name:LEAL-CRUZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12229 JOBEL LN
Mailing Address - Street 2:
Mailing Address - City:BROADWAY
Mailing Address - State:VA
Mailing Address - Zip Code:22815-3100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12229 JOBEL LN
Practice Address - Street 2:
Practice Address - City:BROADWAY
Practice Address - State:VA
Practice Address - Zip Code:22815-3100
Practice Address - Country:US
Practice Address - Phone:540-746-5035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-17
Last Update Date:2025-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer