Provider Demographics
NPI:1679926646
Name:CRUZ, MICHELLE (OD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CRUZ
Suffix:
Gender:F
Credentials:OD
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 32
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS REY
Mailing Address - State:CA
Mailing Address - Zip Code:92068-0032
Mailing Address - Country:US
Mailing Address - Phone:562-826-8000
Mailing Address - Fax:
Practice Address - Street 1:32245 MISSION TRL STE D4
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4528
Practice Address - Country:US
Practice Address - Phone:951-674-1561
Practice Address - Fax:951-674-5300
Is Sole Proprietor?:No
Enumeration Date:2016-07-14
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33482152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1679926646OtherOPTOMETRY