Provider Demographics
NPI:1275289357
Name:CRUZ GUTIERREZ, ESAU
Entity Type:Individual
Prefix:
First Name:ESAU
Middle Name:
Last Name:CRUZ GUTIERREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 GREENE AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-4314
Mailing Address - Country:US
Mailing Address - Phone:845-857-7574
Mailing Address - Fax:
Practice Address - Street 1:SUNY AT STONY BROOK AT STONY BROOK 151 WESTCHESTER HALL
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:845-857-7574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-27
Last Update Date:2022-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental