Provider Demographics
NPI:1891871034
Name:SISEMORE, DANIEL C (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:C
Last Name:SISEMORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:36 W YOKUTS AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5713
Mailing Address - Country:US
Mailing Address - Phone:209-952-3700
Mailing Address - Fax:209-478-3302
Practice Address - Street 1:36 W YOKUTS AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5713
Practice Address - Country:US
Practice Address - Phone:209-952-3700
Practice Address - Fax:209-478-3302
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG11531207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G115311Medicaid
A38375Medicare UPIN
CA00G115311Medicaid