Healthcare Provider Details

I. General information

NPI: 1831584473
Provider Name (Legal Business Name): MARIO CISNEROS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2015
Last Update Date: 09/27/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

653 W 8TH ST # L18
JACKSONVILLE FL
32209-6511
US

IV. Provider business mailing address

SSB-6 400 E 3RD ST
DULUTH MN
55805-1951
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-3907
  • Fax:
Mailing address:
  • Phone: 218-786-8364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number70064
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberOS15211
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: