Provider Demographics
NPI:1710941539
Name:DOMENICK J SISTO M D INC
Entity Type:Organization
Organization Name:DOMENICK J SISTO M D INC
Other - Org Name:LOS ANGELES ORTHOPAEDIC INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOMENICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:SISTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-905-2222
Mailing Address - Street 1:4955 VAN NUYS BLVD
Mailing Address - Street 2:SUITE 615
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1801
Mailing Address - Country:US
Mailing Address - Phone:818-905-2222
Mailing Address - Fax:818-905-8702
Practice Address - Street 1:38660 MEDICAL CENTER DRIVE
Practice Address - Street 2:SUITE A250
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-0000
Practice Address - Country:US
Practice Address - Phone:661-267-7777
Practice Address - Fax:661-267-7101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA061942-71174400000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ36984ZOtherBLUE SHIELD -LANCASTER
CAZZZ36983ZOtherBLUE SHIELD-SHERMAN OAKS
CAW11945BOtherMEDICARE ID-VALENCIA
CADA0572OtherRAILROAD
CAZZZ36983ZOtherBLUE SHIELD-SHERMAN OAKS
CADA0572OtherRAILROAD
CAW11945AMedicare ID - Type UnspecifiedMEDICARE - LANCASTER
CAW11945BOtherMEDICARE ID-VALENCIA
CA0368280002Medicare NSC