Healthcare Provider Details

I. General information

NPI: 1164097341
Provider Name (Legal Business Name): CISCO MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2021
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 E VERDUGO AVE STE 206
BURBANK CA
91502-1342
US

IV. Provider business mailing address

18518 SHERMAN WAY
RESEDA CA
91335-4212
US

V. Phone/Fax

Practice location:
  • Phone: 818-757-0954
  • Fax: 818-757-0963
Mailing address:
  • Phone: 818-757-0954
  • Fax: 818-757-0963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOSE FRANCISCO MARTINEZ CARDENAS
Title or Position: PRESIDENT/MEDICAL DIRECTOR
Credential: MD
Phone: 818-757-0954