Provider Demographics
NPI:1003004524
Name:CISNEROS, CHRISTINE MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:MARIE
Last Name:CISNEROS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2760 EMBER WAY
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-6462
Mailing Address - Country:US
Mailing Address - Phone:734-913-0949
Mailing Address - Fax:
Practice Address - Street 1:700 E BEARDSLEY AVE
Practice Address - Street 2:STE 100
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-3366
Practice Address - Country:US
Practice Address - Phone:574-206-8010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-10
Last Update Date:2012-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407270204D00000X, 2083X0100X
IL036-108497204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700H231390OtherBCBSM GROUP NUMBER
MI700H231390OtherBCBSM GROUP NUMBER