Healthcare Provider Details

I. General information

NPI: 1184703399
Provider Name (Legal Business Name): LUIS A CISNEROS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 10/27/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 36TH AV
VERO BEACH FL
32967
US

IV. Provider business mailing address

1000 36TH AV
VERO BEACH FL
32960
US

V. Phone/Fax

Practice location:
  • Phone: 772-567-4311
  • Fax: 570-693-2123
Mailing address:
  • Phone: 772-567-4311
  • Fax: 772-794-1474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME99482
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: