Provider Demographics
NPI:1669424446
Name:CRUZ, JESENIA (MD)
Entity type:Individual
Prefix:
First Name:JESENIA
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 1:425 ESSJAY RD
Mailing Address - Street 2:STE 170
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5782
Mailing Address - Country:US
Mailing Address - Phone:716-630-1219
Mailing Address - Fax:716-817-1726
Practice Address - Street 1:6950 S TRANSIT RD
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-6333
Practice Address - Country:US
Practice Address - Phone:716-630-1143
Practice Address - Fax:716-817-1765
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228571207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11489395OtherCAQH
NY060720000023OtherFIDELIS
NY175204BFOtherPREFERRED CARE
NYP010238304OtherBLUE CHOICE
NY00027387401OtherUNIVERA
NYP010238304OtherBLUE CHOICE
NYDD6961Medicare ID - Type Unspecified