Provider Demographics
NPI:1932165537
Name:CRUZ, LOURDES M (MD)
Entity Type:Individual
Prefix:
First Name:LOURDES
Middle Name:M
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 1:20613 N BROAD ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-3717
Mailing Address - Country:US
Mailing Address - Phone:217-854-3881
Mailing Address - Fax:217-854-3894
Practice Address - Street 1:20613 N BROAD ST
Practice Address - Street 2:SUITE B
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626-3717
Practice Address - Country:US
Practice Address - Phone:217-854-3881
Practice Address - Fax:217-854-3894
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036096484207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036096484Medicaid
IL036096484Medicaid
G59276Medicare UPIN