Provider Demographics
NPI:1447205737
Name:ESTILLORE-CRUZ, ALICIA S (MD)
Entity Type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:S
Last Name:ESTILLORE-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 1:603 WHEAT AVE
Mailing Address - Street 2:BAINBRIDGE
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-4360
Mailing Address - Country:US
Mailing Address - Phone:229-246-1209
Mailing Address - Fax:229-243-7707
Practice Address - Street 1:603 WHEAT AVE
Practice Address - Street 2:BAINBRIDGE
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-4360
Practice Address - Country:US
Practice Address - Phone:229-246-1209
Practice Address - Fax:229-243-7707
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045780208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000803393AMedicaid
GA000803393BMedicaid
GA000803393AMedicaid
GA37BBFFTMedicare ID - Type Unspecified