Provider Demographics
NPI:1962926956
Name:CRUZ, MARIO (OD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:CRUZ
Suffix:
Gender:M
Credentials:OD
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 947
Mailing Address - Street 2:
Mailing Address - City:DILLINGHAM
Mailing Address - State:AK
Mailing Address - Zip Code:99576
Mailing Address - Country:US
Mailing Address - Phone:775-315-7882
Mailing Address - Fax:
Practice Address - Street 1:6000 KANAKANAK
Practice Address - Street 2:
Practice Address - City:DILLINGHAM
Practice Address - State:AK
Practice Address - Zip Code:99576
Practice Address - Country:US
Practice Address - Phone:907-842-5201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-01
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK122876152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1674551Medicaid