Healthcare Provider Details

I. General information

NPI: 1124134770
Provider Name (Legal Business Name): IDALIA CRUZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 DEBEVOISE ST STE 5
BROOKLYN NY
11206-4194
US

IV. Provider business mailing address

145 W 15TH ST 2ND FLOOR
NEW YORK NY
10011-6701
US

V. Phone/Fax

Practice location:
  • Phone: 718-963-4430
  • Fax: 646-398-2794
Mailing address:
  • Phone: 212-924-6324
  • Fax: 212-691-5635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number172165
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier040426033250
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerFIDELIS PROVIDER NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: