Provider Demographics
NPI:1053381269
Name:LYDIA A CRUZ MD INC
Entity type:Organization
Organization Name:LYDIA A CRUZ MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-244-5204
Mailing Address - Street 1:PO BOX 1749
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-0150
Mailing Address - Country:US
Mailing Address - Phone:760-244-5204
Mailing Address - Fax:760-947-7489
Practice Address - Street 1:15248 ELEVENTH ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392
Practice Address - Country:US
Practice Address - Phone:760-245-8691
Practice Address - Fax:760-843-6127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA26050207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A260500Medicaid
CA00A260500Medicaid
00A260500Medicare ID - Type Unspecified