Provider Demographics
NPI:1043560907
Name:CISNEROS, RICARDO (CPHT)
Entity Type:Individual
Prefix:MR
First Name:RICARDO
Middle Name:
Last Name:CISNEROS
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:
Other - Last Name:CISNEROS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11519 LINGO
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023
Mailing Address - Country:US
Mailing Address - Phone:915-433-0765
Mailing Address - Fax:
Practice Address - Street 1:2748 WORTH RD
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-6031
Practice Address - Country:US
Practice Address - Phone:210-221-6428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX242092183700000X
TX500107010057077183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician