Provider Demographics
NPI:1578241618
Name:SISIC, BENJAMIN (RD, LD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:SISIC
Suffix:
Gender:M
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:278 BALABAN CIR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-5150
Mailing Address - Country:US
Mailing Address - Phone:678-865-9922
Mailing Address - Fax:
Practice Address - Street 1:278 BALABAN CIR
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-5150
Practice Address - Country:US
Practice Address - Phone:678-865-9922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD004467133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered