Provider Demographics
NPI:1598739575
Name:SISEMORE, DAVID LAWRENCE (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LAWRENCE
Last Name:SISEMORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 J ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95811-3010
Mailing Address - Country:US
Mailing Address - Phone:916-313-8400
Mailing Address - Fax:916-444-5620
Practice Address - Street 1:1820 J ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-3010
Practice Address - Country:US
Practice Address - Phone:916-313-8400
Practice Address - Fax:916-444-5260
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A93272084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABK021ZOtherMEDICARE PTAN
BK021Medicare PIN
CARES000Medicare UPIN