Provider Demographics
NPI:1043884760
Name:CRUZ, EVELYN
Entity type:Individual
Prefix:
First Name:EVELYN
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 1:36 NORTHFIELD CT
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-1661
Mailing Address - Country:US
Mailing Address - Phone:347-216-4077
Mailing Address - Fax:
Practice Address - Street 1:36 NORTHFIELD CT
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10303-1661
Practice Address - Country:US
Practice Address - Phone:347-216-4077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY112123918OtherSTATE ID