Provider Demographics
NPI:1730404476
Name:CRUZ, KRISTINE (MD)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
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:PO BOX 142
Mailing Address - Street 2:
Mailing Address - City:TOHATCHI
Mailing Address - State:NM
Mailing Address - Zip Code:87325-0142
Mailing Address - Country:US
Mailing Address - Phone:505-733-8100
Mailing Address - Fax:505-733-2388
Practice Address - Street 1:PO BOX 142
Practice Address - Street 2:
Practice Address - City:TOHATCHI
Practice Address - State:NM
Practice Address - Zip Code:87325-0142
Practice Address - Country:US
Practice Address - Phone:505-733-8100
Practice Address - Fax:505-733-2388
Is Sole Proprietor?:No
Enumeration Date:2010-04-06
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT42.0012719207Q00000X
NMMD2020-0899207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM73330582Medicaid