Provider Demographics
NPI:1619942612
Name:SISNEROS, ERNEST E JR (OD)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:E
Last Name:SISNEROS
Suffix:JR
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:2550 EASTERN BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-1500
Practice Address - Country:US
Practice Address - Phone:334-274-2020
Practice Address - Fax:334-396-9924
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-B01-TA-673152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALS-B01-TA-673OtherAL BOARD OF OPTOMETRY
ALS-B01-TA-673OtherAL BOARD OF OPTOMETRY
ALM1033632OtherDEA
ALV05202Medicare UPIN