Provider Demographics
NPI:1508020918
Name:SISSON, RICHARD B (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:B
Last Name:SISSON
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 1:6501 LOISDALE CT FL 7
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22150-1826
Mailing Address - Country:US
Mailing Address - Phone:703-922-1152
Mailing Address - Fax:
Practice Address - Street 1:6501 LOISDALE CT FL 7
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-1826
Practice Address - Country:US
Practice Address - Phone:703-922-1152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101264197207QS0010X
CODR46752390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO21781OtherKAISER COMMERCIAL NUMBER
CO14226049Medicaid
COCOAAA1880Medicare PIN