Provider Demographics
NPI:1164719357
Name:CORNEJO CISNEROS, ENRIQUE (MD)
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:
Last Name:CORNEJO 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 1:441 E ERIE ST APT 3205
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4429
Mailing Address - Country:US
Mailing Address - Phone:314-560-2165
Mailing Address - Fax:
Practice Address - Street 1:441 E ERIE ST APT 3205
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4429
Practice Address - Country:US
Practice Address - Phone:314-560-2165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011015465207R00000X
IL125.064371207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine