Provider Demographics
NPI:1437116746
Name:ANTONIO, ANDRES CRUZ (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDRES
Middle Name:CRUZ
Last Name:ANTONIO
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 1:625 GRAMATAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:MT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10552
Mailing Address - Country:US
Mailing Address - Phone:914-668-9164
Mailing Address - Fax:914-664-2610
Practice Address - Street 1:625 GRAMATAN AVENUE
Practice Address - Street 2:
Practice Address - City:MT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10552
Practice Address - Country:US
Practice Address - Phone:914-668-9164
Practice Address - Fax:914-664-2610
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY139555207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00599826Medicaid
NY71A131Medicare ID - Type Unspecified
A63909Medicare UPIN