Provider Demographics
NPI:1588868616
Name:MATOS-CRUZ, MARIO (MD)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:MATOS-CRUZ
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:PO BOX 432
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-0432
Mailing Address - Country:US
Mailing Address - Phone:606-218-6402
Mailing Address - Fax:606-218-7502
Practice Address - Street 1:830 W HIGH ST STE 207
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-3975
Practice Address - Country:US
Practice Address - Phone:419-996-4011
Practice Address - Fax:419-996-4012
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0027419208G00000X
OH35065706208G00000X
KY29040208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20010800AMedicaid
OH0065177Medicaid
OH0065177Medicaid
IN20010800AMedicaid
IN20010800AMedicaid