Healthcare Provider Details

I. General information

NPI: 1104184944
Provider Name (Legal Business Name): MARIANA VIGIOLA CRUZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N WESTMORELAND RD STE 100
LAKE FOREST IL
60045-1671
US

IV. Provider business mailing address

800 N WESTMORELAND RD STE 100
LAKE FOREST IL
60045-1671
US

V. Phone/Fax

Practice location:
  • Phone: 847-535-7208
  • Fax:
Mailing address:
  • Phone: 847-535-7208
  • Fax: 224-271-4600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberD0101830
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number297702-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036153330
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM-2253
License Number StateGU
# 5
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number036153330
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: