Healthcare Provider Details

I. General information

NPI: 1023249174
Provider Name (Legal Business Name): JOSE GOMEZ CISNEROS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2009
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3140 N 35TH AVE STE 7
PHOENIX AZ
85017-5270
US

IV. Provider business mailing address

3140 N 35TH AVE STE 7
PHOENIX AZ
85017-5270
US

V. Phone/Fax

Practice location:
  • Phone: 602-353-6656
  • Fax: 602-442-2065
Mailing address:
  • Phone: 23-536-6566
  • Fax: 602-442-2065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number50002
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number50002
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: