Provider Demographics
NPI:1104184944
Name:VIGIOLA CRUZ, MARIANA
Entity Type:Individual
Prefix:
First Name:MARIANA
Middle Name:
Last Name:VIGIOLA CRUZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 N WESTMORELAND RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1671
Mailing Address - Country:US
Mailing Address - Phone:847-535-7208
Mailing Address - Fax:224-271-4600
Practice Address - Street 1:800 N WESTMORELAND RD STE 100
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1671
Practice Address - Country:US
Practice Address - Phone:847-535-7208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2021-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY297702-1208600000X
IL036153330208600000X, 2086S0127X
GUM-2253208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery