Healthcare Provider Details

I. General information

NPI: 1801893854
Provider Name (Legal Business Name): GREGORIO ALFONSO CISNEROS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2005
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 OLD KINGS RD N STE J
PALM COAST FL
32137-8283
US

IV. Provider business mailing address

17 OLD KINGS RD N STE J
PALM COAST FL
32137-8283
US

V. Phone/Fax

Practice location:
  • Phone: 386-446-4141
  • Fax: 386-264-6764
Mailing address:
  • Phone: 386-446-4141
  • Fax: 386-264-6764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME84611
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: