Provider Demographics
NPI:1922077585
Name:SISON, DEMOSTENES R (MD)
Entity Type:Individual
Prefix:DR
First Name:DEMOSTENES
Middle Name:R
Last Name:SISON
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 1:4520 OBERLIN AVE
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-3173
Mailing Address - Country:US
Mailing Address - Phone:440-282-1485
Mailing Address - Fax:440-282-5328
Practice Address - Street 1:4520 OBERLIN AVE
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-3173
Practice Address - Country:US
Practice Address - Phone:440-282-1485
Practice Address - Fax:440-282-5328
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0269445Medicaid
OH0269445Medicaid
OHSI0409073Medicare ID - Type Unspecified