Provider Demographics
NPI:1619956935
Name:CRUZ, PAUL J
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:CRUZ
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:PO BOX 155
Mailing Address - Street 2:CHRISTOPHER GREATER AREA RURAL HEALTH PLANNING CORP
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822
Mailing Address - Country:US
Mailing Address - Phone:618-724-2401
Mailing Address - Fax:618-724-4628
Practice Address - Street 1:3303 LOGAN DR
Practice Address - Street 2:REA CLINIC HERRIN
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948
Practice Address - Country:US
Practice Address - Phone:618-993-5767
Practice Address - Fax:618-724-2571
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036077364207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL027163OtherHEALTH ALLIANCE
IL036077364Medicaid
IL175114OtherHEALTHLINK
D89412Medicare UPIN
K03111Medicare ID - Type Unspecified