Provider Demographics
NPI:1104916535
Name:CRUZ, ALFREDO BAMBA (MD)
Entity type:Individual
Prefix:DR
First Name:ALFREDO
Middle Name:BAMBA
Last Name:CRUZ
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 1:45 2ND ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-3928
Mailing Address - Country:US
Mailing Address - Phone:518-272-7191
Mailing Address - Fax:518-272-7234
Practice Address - Street 1:45 2ND ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-3928
Practice Address - Country:US
Practice Address - Phone:518-272-7191
Practice Address - Fax:518-272-7234
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY142744207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY08287OtherMVP
NY10000414OtherCDPHP
79E301OtherBC
NY00531535Medicaid
NY00531535Medicaid
79E301OtherBC