Provider Demographics
NPI:1801906102
Name:CRUZ, NICHOLE M (OD)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:M
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 1:675 WOLF RD
Mailing Address - Street 2:P.O.BOX 2
Mailing Address - City:RANDOM LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:53075-1264
Mailing Address - Country:US
Mailing Address - Phone:920-994-8500
Mailing Address - Fax:920-994-8550
Practice Address - Street 1:675 WOLF RD
Practice Address - Street 2:
Practice Address - City:RANDOM LAKE
Practice Address - State:WI
Practice Address - Zip Code:53075-1264
Practice Address - Country:US
Practice Address - Phone:920-994-8500
Practice Address - Fax:920-994-8550
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2823-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38623000Medicaid
WIU92443Medicare UPIN
WI000047262Medicare UPIN
WI38623000Medicaid