Healthcare Provider Details

I. General information

NPI: 1457301129
Provider Name (Legal Business Name): SALVADOR CENICEROS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 N BENTON AVE
SPRINGFIELD MO
65806-1102
US

IV. Provider business mailing address

440 E TAMPA ST
SPRINGFIELD MO
65806-1131
US

V. Phone/Fax

Practice location:
  • Phone: 417-851-1563
  • Fax: 417-831-8033
Mailing address:
  • Phone: 417-831-0150
  • Fax: 417-831-8033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2010006881
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01052420A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: