Healthcare Provider Details

I. General information

NPI: 1477101764
Provider Name (Legal Business Name): ROGER BENJAMIN CISNEROS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2019
Last Update Date: 12/19/2019
Certification Date: 12/19/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 S HIGHLAND AVE
CLEARWATER FL
33756-4446
US

IV. Provider business mailing address

1395 NW 167TH ST
MIAMI GARDENS FL
33169-5710
US

V. Phone/Fax

Practice location:
  • Phone: 727-219-1833
  • Fax: 727-298-8794
Mailing address:
  • Phone: 727-219-1833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME142324
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11422103-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: