Provider Demographics
NPI:1922071448
Name:VITO CRUZ, MARISSA GALVEZ (MD)
Entity type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:GALVEZ
Last Name:VITO CRUZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARISSA
Other - Middle Name:G
Other - Last Name:VITOCRUZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-302-6567
Mailing Address - Fax:
Practice Address - Street 1:100 15TH ST NW
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1616
Practice Address - Country:US
Practice Address - Phone:276-679-9002
Practice Address - Fax:276-679-9078
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101221333207P00000X, 207Q00000X, 208M00000X
TN48344207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP01245198OtherRAILROAD MEDICARE
TN1527723Medicaid
VA1922071448Medicaid
TN103I088932Medicare PIN
TN103I082890Medicare PIN
VAP01245198OtherRAILROAD MEDICARE
VA1922071448Medicaid
VAVV4041BMedicare PIN
TN103I080288Medicare PIN
VAVV4041DMedicare PIN
VA015932W82Medicare PIN
VAV V4041AMedicare PIN