Provider Demographics
NPI:1639250558
Name:REYNA, ROBERTO CISNEROS (MD)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:CISNEROS
Last Name:REYNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ROBERTO
Other - Middle Name:REYNA
Other - Last Name:CISNEROS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:65 HEALTH CARE LN
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-4006
Mailing Address - Country:US
Mailing Address - Phone:304-263-6997
Mailing Address - Fax:304-263-8827
Practice Address - Street 1:65 HEALTH CARE LN
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-4006
Practice Address - Country:US
Practice Address - Phone:304-263-6997
Practice Address - Fax:304-263-8827
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19524207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0082008000Medicaid
WVG86158Medicare UPIN
WV0082008000Medicaid