Provider Demographics
NPI:1215933353
Name:CERVANTES, LUIS A (MD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:A
Last Name:CERVANTES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 MARTER AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-3124
Mailing Address - Country:US
Mailing Address - Phone:856-727-1000
Mailing Address - Fax:856-727-1059
Practice Address - Street 1:500 PLAZA COURT
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-3124
Practice Address - Country:US
Practice Address - Phone:570-426-2758
Practice Address - Fax:570-426-2665
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA44094207T00000X
PAMD462928207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0108926000OtherAMERIHEALTH HMO
NJE01236OtherAMERIHEALTH ADMINISTRATOR
PA1034000720003Medicaid
PA620691PZPOtherMEDICARE
NJ34701OtherAETNA/USHC