Provider Demographics
NPI:1851311658
Name:SIFONTES, THEODORE J (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:J
Last Name:SIFONTES
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 1:107 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-4002
Mailing Address - Country:US
Mailing Address - Phone:914-699-7200
Mailing Address - Fax:914-699-0837
Practice Address - Street 1:107 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-4002
Practice Address - Country:US
Practice Address - Phone:914-699-7200
Practice Address - Fax:914-699-0837
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY169644207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01553626Medicaid
48F041Medicare ID - Type Unspecified
NY01553626Medicaid