Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208200000X | Surgeon | 036153330 | IL |
N | 208600000X | Surgeon | 036153330 | IL |
N | 208200000X | Surgeon | 297702-1 | NY |
N | 208600000X | Surgeon | 297702-1 | NY |
N | 208200000X | Surgeon | M-2253 | GU |
N | 208600000X | Surgeon | M-2253 | GU |
Y | 2086S0127X | Trauma Surgeon | 036153330 | IL |
NPI | 1104184944 |
---|---|
Provider Name | Mariana Vigiola Cruz |
First Address | Lake Forest, IL 60045-1671 |
Second Address | Lake Forest, IL 60045-1671 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/04/2012 |
Last Update Date | 23/05/2021 |