Provider Demographics
NPI:1477101764
Name:CISNEROS, ROGER BENJAMIN (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:BENJAMIN
Last Name: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 1:1395 NW 167TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5710
Mailing Address - Country:US
Mailing Address - Phone:727-219-1833
Mailing Address - Fax:
Practice Address - Street 1:855 S HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-4446
Practice Address - Country:US
Practice Address - Phone:727-219-1833
Practice Address - Fax:727-298-8794
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME142324207Q00000X
UT11422103-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine