Basic Information
| Provider Information | |||||||||
| NPI: | 1962615922 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CERVANTES | ||||||||
| FirstName: | LORENZO | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 87 GRANDVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067082514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035742020 | ||||||||
| FaxNumber: | 2035962230 | ||||||||
| Practice Location | |||||||||
| Address1: | 87 GRANDVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067082514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035742020 | ||||||||
| FaxNumber: | 2035962230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 01/18/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 49775 | CT | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 1962615922 | 05 | CT | MEDICAID |