Provider Demographics
NPI:1144414921
Name:TOMACRUZ, MOSES GODOFREDO (MD)
Entity type:Individual
Prefix:
First Name:MOSES GODOFREDO
Middle Name:
Last Name:TOMACRUZ
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 1:24600 W 127TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-9507
Mailing Address - Country:US
Mailing Address - Phone:815-731-9000
Mailing Address - Fax:815-731-9001
Practice Address - Street 1:1502 PARKVIEW AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1821
Practice Address - Country:US
Practice Address - Phone:815-381-7250
Practice Address - Fax:815-381-7251
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-120622207Q00000X
PAMT186770207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36120622Medicaid
IL553180OtherMEDICARE GROUP #
IL801570OtherMEDICARE GROUP #
IL834370OtherMEDICARE GROUP #
IL553180OtherMEDICARE GROUP #
IL36120622Medicaid
IL834370OtherMEDICARE GROUP #