Provider Demographics
NPI:1366424228
Name:CRUZ, TODD JASON (PT)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:JASON
Last Name:CRUZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:STE 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:2701 NW VAUGHN ST
Practice Address - Street 2:STE 155
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5311
Practice Address - Country:US
Practice Address - Phone:503-227-3479
Practice Address - Fax:503-223-4838
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3020225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR295703Medicaid
OR295703Medicaid