Provider Demographics
NPI:1881396653
Name:CRUZ, IDAMYLIZ
Entity type:Individual
Prefix:
First Name:IDAMYLIZ
Middle Name:
Last Name:CRUZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 61 BOX 4266
Mailing Address - Street 2:
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976-9712
Mailing Address - Country:US
Mailing Address - Phone:787-605-5822
Mailing Address - Fax:
Practice Address - Street 1:11-C PELLIN CRUZ
Practice Address - Street 2:
Practice Address - City:TRUJILLO ALTO
Practice Address - State:PR
Practice Address - Zip Code:00976-0097
Practice Address - Country:US
Practice Address - Phone:787-605-5822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist