Provider Demographics
NPI:1609948884
Name:SISSELMAN, STEPHEN G (DO)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:G
Last Name:SISSELMAN
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 1:627 BROADWAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-5031
Mailing Address - Country:US
Mailing Address - Phone:516-308-4040
Mailing Address - Fax:516-804-6386
Practice Address - Street 1:627 BROADWAY
Practice Address - Street 2:STE 1
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-5031
Practice Address - Country:US
Practice Address - Phone:516-308-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216161207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02236377Medicaid
H24130Medicare UPIN