Provider Demographics
NPI:1467131763
Name:CRUZ GUTIERREZ, SERGIO SAUL
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:SAUL
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 1:1836 WESLEY AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-5726
Mailing Address - Country:US
Mailing Address - Phone:708-829-5052
Mailing Address - Fax:
Practice Address - Street 1:1620 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3801
Practice Address - Country:US
Practice Address - Phone:312-942-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.435257163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse