Provider Demographics
NPI:1801893854
Name:CISNEROS, GREGORIO ALFONSO (MD)
Entity type:Individual
Prefix:
First Name:GREGORIO
Middle Name:ALFONSO
Last Name:CISNEROS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 OLD KINGS RD N STE J
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-8283
Mailing Address - Country:US
Mailing Address - Phone:386-446-4141
Mailing Address - Fax:386-264-6764
Practice Address - Street 1:17 OLD KINGS RD N STE J
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8283
Practice Address - Country:US
Practice Address - Phone:386-446-4141
Practice Address - Fax:386-264-6764
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84611207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H64840Medicare UPIN
FLE7696ZMedicare ID - Type Unspecified