Provider Demographics
NPI:1922036227
Name:CRUZ, LOURDES FORLALES (MD)
Entity Type:Individual
Prefix:DR
First Name:LOURDES
Middle Name:FORLALES
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 1:71 KENMORE AVE
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-3031
Mailing Address - Country:US
Mailing Address - Phone:716-832-3111
Mailing Address - Fax:716-836-3212
Practice Address - Street 1:71 KENMORE AVE
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-3031
Practice Address - Country:US
Practice Address - Phone:716-832-3111
Practice Address - Fax:716-836-3212
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1361182080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00951822Medicaid