Healthcare Provider Details

I. General information

NPI: 1730404476
Provider Name (Legal Business Name): KRISTINE CRUZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2010
Last Update Date: 12/31/2024
Certification Date: 12/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 142
TOHATCHI NM
87325-0142
US

IV. Provider business mailing address

PO BOX 142
TOHATCHI NM
87325-0142
US

V. Phone/Fax

Practice location:
  • Phone: 505-733-8100
  • Fax: 505-733-2388
Mailing address:
  • Phone: 505-733-8100
  • Fax: 505-733-2388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number42.0012719
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2020-0899
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: