Provider Demographics
NPI:1174257521
Name:CISNEROS, SERGIO (OD)
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:CISNEROS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11915 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-3216
Mailing Address - Country:US
Mailing Address - Phone:718-805-0570
Mailing Address - Fax:718-805-5621
Practice Address - Street 1:11915 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-3216
Practice Address - Country:US
Practice Address - Phone:718-805-0700
Practice Address - Fax:718-805-5621
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0009594152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty