Provider Demographics
NPI:1598705196
Name:CRUZ, KENNETH Q (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:Q
Last Name:CRUZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:830 WEST RTE 22
Mailing Address - Street 2:SUITE 50
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047
Mailing Address - Country:US
Mailing Address - Phone:866-344-0543
Mailing Address - Fax:866-344-3934
Practice Address - Street 1:800 W CENTRAL RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2349
Practice Address - Country:US
Practice Address - Phone:800-655-2656
Practice Address - Fax:412-822-7411
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90441207R00000X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A904410OtherBLUE SHIELD OF CA
CA00A904410Medicaid
H67454Medicare UPIN
CA00A904410Medicaid