Provider Demographics
NPI:1619946522
Name:TISSERA, JOSE SAUL (MD)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:SAUL
Last Name:TISSERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8301 ARLINGTON BLVD
Mailing Address - Street 2:STE 305
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2902
Mailing Address - Country:US
Mailing Address - Phone:703-573-2301
Mailing Address - Fax:703-573-5104
Practice Address - Street 1:8301 ARLINGTON BLVD
Practice Address - Street 2:STE 305
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2902
Practice Address - Country:US
Practice Address - Phone:703-573-2301
Practice Address - Fax:703-573-5104
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101023093207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B95036Medicare UPIN
VATI457447Medicare ID - Type Unspecified