Provider Demographics
NPI:1336781038
Name:CRUZ ECHEVARRIA, JUAN CARLOS (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:CRUZ ECHEVARRIA
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 1:1775 BALLARD RD
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068
Mailing Address - Country:US
Mailing Address - Phone:847-318-9340
Mailing Address - Fax:847-318-2966
Practice Address - Street 1:1775 BALLARD RD
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1005
Practice Address - Country:US
Practice Address - Phone:847-318-9340
Practice Address - Fax:847-318-2966
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-14
Last Update Date:2021-09-27
Deactivation Date:2021-07-02
Deactivation Code:
Reactivation Date:2021-08-03
Provider Licenses
StateLicense IDTaxonomies
IL125.079141390200000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty