Provider Demographics
NPI:1609960475
Name:SIOKOS, ZISSIE (OD)
Entity Type:Individual
Prefix:DR
First Name:ZISSIE
Middle Name:
Last Name:SIOKOS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 GREEN LANE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128
Mailing Address - Country:US
Mailing Address - Phone:215-421-7755
Mailing Address - Fax:
Practice Address - Street 1:860 E SWEDESFORD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-2130
Practice Address - Country:US
Practice Address - Phone:610-265-2020
Practice Address - Fax:610-265-4054
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPAOEG1082152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017617980005Medicaid
PA0017617980005Medicaid