Provider Demographics
NPI:1063482123
Name:SIASOCO, SIXTO ANDRES (MD)
Entity Type:Individual
Prefix:DR
First Name:SIXTO
Middle Name:ANDRES
Last Name:SIASOCO
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 1:415 PORT WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-4201
Mailing Address - Country:US
Mailing Address - Phone:516-883-0218
Mailing Address - Fax:516-767-0894
Practice Address - Street 1:415 PORT WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-4201
Practice Address - Country:US
Practice Address - Phone:516-883-0218
Practice Address - Fax:516-767-0894
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113792207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00207763Medicaid
NYB15063Medicare UPIN
NY00207763Medicaid