Healthcare Provider Details

I. General information

NPI: 1417350026
Provider Name (Legal Business Name): LIGIA ELENA CISNEROS-GONZALEZ M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2014
Last Update Date: 09/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 W BETHUNE ST APT 1709
DETROIT MI
48202-2666
US

IV. Provider business mailing address

1350 W BETHUNE ST APT 1709
DETROIT MI
48202-2666
US

V. Phone/Fax

Practice location:
  • Phone: 734-548-2425
  • Fax:
Mailing address:
  • Phone: 734-548-2425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4301104902
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: