Provider Demographics
NPI:1558437020
Name:SISSON, MARK THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:THOMAS
Last Name:SISSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:300 W HOSPITAL RD
Mailing Address - Street 2:EISENHOWER ARMY MEDICAL CENTER ATTN CREDENTIALS
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5741
Mailing Address - Country:US
Mailing Address - Phone:706-787-0127
Mailing Address - Fax:706-787-8176
Practice Address - Street 1:300 W HOSPITAL RD
Practice Address - Street 2:EISENHOWER ARMY MEDICAL CENTER ATTN CREDENTIALS
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5741
Practice Address - Country:US
Practice Address - Phone:706-787-0127
Practice Address - Fax:706-787-8176
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2017-07-06
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Provider Licenses
StateLicense IDTaxonomies
VA0101048953207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD 000Medicare UPIN