Provider Demographics
NPI:1699783571
Name:CISNEROS, ALICE (DPM)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:CISNEROS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4225 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076
Mailing Address - Country:US
Mailing Address - Phone:847-676-3338
Mailing Address - Fax:847-676-3668
Practice Address - Street 1:4225 MAIN ST
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076
Practice Address - Country:US
Practice Address - Phone:847-676-3338
Practice Address - Fax:847-676-3668
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004525213E00000X
WI715025213E00000X
IN070007444213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6000174548OtherBLUE CROSS
INU28723OtherUPIN IN
IL946190Medicare PIN
INU28723OtherUPIN IN
IL0943020001Medicare NSC