Healthcare Provider Details

I. General information

NPI: 1962853408
Provider Name (Legal Business Name): SEBASTIAN ALFREDO CISNEROS TRUJILLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W 168TH ST FL 4
NEW YORK NY
10032-3720
US

IV. Provider business mailing address

622 W 168TH ST FL 4
NEW YORK NY
10032-3720
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-9099
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number299723
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: