Provider Demographics
NPI:1588471106
Name:GONZALEZ CRUZ, JOSE EDGARDO (IDHS)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:EDGARDO
Last Name:GONZALEZ CRUZ
Suffix:
Gender:M
Credentials:IDHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5019 GREEN BLUFF CT
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-9327
Mailing Address - Country:US
Mailing Address - Phone:787-478-1112
Mailing Address - Fax:
Practice Address - Street 1:5019 GREEN BLUFF CT
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-9327
Practice Address - Country:US
Practice Address - Phone:787-478-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians