Healthcare Provider Details

I. General information

NPI: 1942732409
Provider Name (Legal Business Name): VICTOR MANUEL CISNEROS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 12/08/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S RTE. 128-01
ORANGE CA
92868-3201
US

IV. Provider business mailing address

101 THE CITY DR S RTE. 128-01
ORANGE CA
92868-3201
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-5239
  • Fax:
Mailing address:
  • Phone: 714-456-5239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA158041
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: