Healthcare Provider Details

I. General information

NPI: 1144336173
Provider Name (Legal Business Name): ALFRED CISNEROS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4777 N HARLEM AVE
HARWOOD HEIGHTS IL
60706-4658
US

IV. Provider business mailing address

4777 N HARLEM AVE
HARWOOD HEIGHTS IL
60706-4658
US

V. Phone/Fax

Practice location:
  • Phone: 708-867-4020
  • Fax: 708-867-5306
Mailing address:
  • Phone: 708-867-4020
  • Fax: 708-867-5306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-061744
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: