Provider Demographics
NPI:1457301129
Name:CENICEROS, SALVADOR (MD)
Entity Type:Individual
Prefix:
First Name:SALVADOR
Middle Name:
Last Name:CENICEROS
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 1:440 E TAMPA ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65806-1131
Mailing Address - Country:US
Mailing Address - Phone:417-831-0150
Mailing Address - Fax:417-831-8033
Practice Address - Street 1:618 N BENTON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-1102
Practice Address - Country:US
Practice Address - Phone:417-851-1563
Practice Address - Fax:417-831-8033
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20100068812084P0800X
IN01052420A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2010006881OtherSTATE LICENSE
MO204132302Medicaid
MOP01038084OtherRAILROAD MEDICARE
MO1457301129Medicaid
H20865Medicare UPIN