Provider Demographics
NPI:1164097341
Name:CISCO MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:CISCO MEDICAL GROUP, INC
Other - Org Name:CISCO MEDICAL GROUP - BURBANK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:FRANCISCO
Authorized Official - Last Name:MARTINEZ CARDENAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-757-0954
Mailing Address - Street 1:18518 SHERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-4212
Mailing Address - Country:US
Mailing Address - Phone:818-757-0954
Mailing Address - Fax:818-757-0963
Practice Address - Street 1:290 E VERDUGO AVE STE 206
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502-1342
Practice Address - Country:US
Practice Address - Phone:818-757-0954
Practice Address - Fax:818-757-0963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-20
Last Update Date:2023-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D1013422OtherCLIA