Provider Demographics
NPI:1215721188
Name:CRUZ GINIEBRA, GUSTAVO (NP)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:CRUZ GINIEBRA
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 SAINT JOHN ST
Mailing Address - Street 2:
Mailing Address - City:MANVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08835-1148
Mailing Address - Country:US
Mailing Address - Phone:551-300-4947
Mailing Address - Fax:
Practice Address - Street 1:1015 SAINT JOHN ST
Practice Address - Street 2:
Practice Address - City:MANVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08835-1148
Practice Address - Country:US
Practice Address - Phone:551-300-4947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15314100207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine