Provider Demographics
NPI:1891971628
Name:CRUZ, JEANETTE ANUDDIN (MD)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:ANUDDIN
Last Name:CRUZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18463 LIVERNOIS AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2254
Mailing Address - Country:US
Mailing Address - Phone:313-861-4400
Mailing Address - Fax:313-861-5810
Practice Address - Street 1:911 E 9 MILE RD
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1934
Practice Address - Country:US
Practice Address - Phone:248-336-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42393207Q00000X
AZ81714207Q00000X
MI4301095410207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301095410OtherPHYSICIAN LICENSE
AZ491303Medicaid
AZ81714OtherTRANING PERMIT
AZ42393OtherPHYSICIAN LICENSE
AZ42393OtherPHYSICIAN LICENSE