Provider Demographics
NPI:1922080100
Name:SISON, ANTONIO R (MD)
Entity Type:Individual
Prefix:
First Name:ANTONIO
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 1:119 NORMAN DORMINY DR STE C
Mailing Address - Street 2:
Mailing Address - City:FITZGERALD
Mailing Address - State:GA
Mailing Address - Zip Code:31750-8855
Mailing Address - Country:US
Mailing Address - Phone:229-423-5843
Mailing Address - Fax:229-423-9847
Practice Address - Street 1:119 NORMAN DORMINY DR STE C
Practice Address - Street 2:
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750-8855
Practice Address - Country:US
Practice Address - Phone:229-423-5843
Practice Address - Fax:229-423-9847
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053172208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA284021398BMedicaid
GA02BDJLFOtherMEDICARE
GA284021398BMedicaid
GAGRP6149Medicare ID - Type UnspecifiedGROUP ID