Healthcare Provider Details

I. General information

NPI: 1578136792
Provider Name (Legal Business Name): WALTER ANTONIO CISNEROS LOPEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2021
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 S CONGRESS AVE
ATLANTIS FL
33462-1149
US

IV. Provider business mailing address

5301 S CONGRESS AVE
ATLANTIS FL
33462-1149
US

V. Phone/Fax

Practice location:
  • Phone: 561-548-1711
  • Fax: 561-548-1743
Mailing address:
  • Phone: 561-548-1711
  • Fax: 561-548-1743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number20-248
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: