Provider Demographics
NPI:1942334156
Name:LOPEZ CISNEROS, JAVIER A
Entity type:Individual
Prefix:
First Name:JAVIER
Middle Name:A
Last Name:LOPEZ CISNEROS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5456 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-2235
Mailing Address - Country:US
Mailing Address - Phone:404-735-8641
Mailing Address - Fax:
Practice Address - Street 1:5456 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 305
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-2235
Practice Address - Country:US
Practice Address - Phone:404-735-8641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty