Provider Demographics
NPI:1528165131
Name:CRUZ, JOHN NORBERT (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:NORBERT
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 1:24 CONKEY AVE
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:NY
Mailing Address - Zip Code:13815-1774
Mailing Address - Country:US
Mailing Address - Phone:607-336-8965
Mailing Address - Fax:607-336-9097
Practice Address - Street 1:24 CONKEY AVE
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:NY
Practice Address - Zip Code:13815-1774
Practice Address - Country:US
Practice Address - Phone:607-336-8965
Practice Address - Fax:607-336-9097
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-19
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174490-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01105513Medicaid
NY9709654OtherGHI
NY328134OtherMVP
NYDD1336OtherMEDICARE ID UNSPECIFIED
NYC74908Medicare UPIN