Provider Demographics
NPI:1528040813
Name:SISK, JERALD L (MD)
Entity Type:Individual
Prefix:
First Name:JERALD
Middle Name:L
Last Name:SISK
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:PO BOX 668
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80001-0668
Mailing Address - Country:US
Mailing Address - Phone:303-422-9438
Mailing Address - Fax:303-422-9474
Practice Address - Street 1:1850 E EGBERT ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-2404
Practice Address - Country:US
Practice Address - Phone:303-659-1531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18251207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01182518Medicaid
COE94484Medicare UPIN
COC807147Medicare PIN