Provider Demographics
NPI:1609282722
Name:CRUZ REPOLLET, IVAN ARIEL (MD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:ARIEL
Last Name:CRUZ REPOLLET
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 1:4340 W HILLSBOROUGH AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-5522
Mailing Address - Country:US
Mailing Address - Phone:813-425-8970
Mailing Address - Fax:813-425-8925
Practice Address - Street 1:4340 W HILLSBOROUGH AVE STE 210
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-5522
Practice Address - Country:US
Practice Address - Phone:813-425-8970
Practice Address - Fax:813-425-8925
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-09
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13,569-I390200000X
FLME153523208D00000X, 207Q00000X
KS0441252207Q00000X
PR19,231208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty