Provider Demographics
NPI:1497820732
Name:SISON, LOURDES FLORES (MD)
Entity Type:Individual
Prefix:DR
First Name:LOURDES
Middle Name:FLORES
Last Name:SISON
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 1:5330 BRAE BURN PL
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-1515
Mailing Address - Country:US
Mailing Address - Phone:562-480-7362
Mailing Address - Fax:
Practice Address - Street 1:905 E SAN ANTONIO DR
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-2211
Practice Address - Country:US
Practice Address - Phone:562-728-9572
Practice Address - Fax:562-728-9562
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA053598208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A535980Medicaid
CA00A535980Medicaid
CAA53598Medicare ID - Type Unspecified