Healthcare Provider Details

I. General information

NPI: 1972546158
Provider Name (Legal Business Name): ZENAIDA REYES IGNACIO-CRUZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 METZNER RD
LAKE RONKONKOMA NY
11779-2141
US

IV. Provider business mailing address

42 METZNER RD
LAKE RONKONKOMA NY
11779-2141
US

V. Phone/Fax

Practice location:
  • Phone: 631-588-4443
  • Fax: 631-588-1261
Mailing address:
  • Phone: 631-588-4443
  • Fax: 631-588-1261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number153800
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: