Provider Demographics
NPI:1093869141
Name:CRUZ, ELIZABETH M (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:M
Last Name:CRUZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 LEYDEN LN
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2159
Mailing Address - Country:US
Mailing Address - Phone:847-853-7981
Mailing Address - Fax:773-404-0713
Practice Address - Street 1:840 W IRVING PARK RD STE 206
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3011
Practice Address - Country:US
Practice Address - Phone:773-975-6825
Practice Address - Fax:773-404-0713
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085454207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036085454Medicaid
IL335251OtherPTAN
IL335251OtherPTAN