Provider Demographics
NPI:1225143274
Name:SISON, REUVEN FERNANDEZ (MD)
Entity Type:Individual
Prefix:
First Name:REUVEN
Middle Name:FERNANDEZ
Last Name:SISON
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 1:850 S ATLANTIC BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-4727
Mailing Address - Country:US
Mailing Address - Phone:626-607-0333
Mailing Address - Fax:626-607-0379
Practice Address - Street 1:850 S ATLANTIC BLVD STE 102
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-4727
Practice Address - Country:US
Practice Address - Phone:626-607-0333
Practice Address - Fax:626-607-0379
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85883207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A858830Medicaid
CAI50251Medicare UPIN