Provider Demographics
NPI:1730116211
Name:CRUZ, WILFREDO TOMAS CORREA (MD)
Entity Type:Individual
Prefix:DR
First Name:WILFREDO TOMAS
Middle Name:CORREA
Last Name:CRUZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-1311
Mailing Address - Country:US
Mailing Address - Phone:973-866-9612
Mailing Address - Fax:201-653-7960
Practice Address - Street 1:201 SAINT PAULS AVE APT 1D
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-3708
Practice Address - Country:US
Practice Address - Phone:201-656-7400
Practice Address - Fax:201-653-7960
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07690500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0026212Medicaid
NJ0026212Medicaid
NJ121950Medicare PIN