Provider Demographics
NPI:1962678110
Name:GERARDO P. SISON, JR., M.D., P.A.
Entity Type:Organization
Organization Name:GERARDO P. SISON, JR., M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:SISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-787-3422
Mailing Address - Street 1:34650 US HIGHWAY 19 N
Mailing Address - Street 2:SUITE 107
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-2155
Mailing Address - Country:US
Mailing Address - Phone:727-787-3422
Mailing Address - Fax:727-787-5624
Practice Address - Street 1:34650 US HIGHWAY 19 N
Practice Address - Street 2:SUITE 107
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-2155
Practice Address - Country:US
Practice Address - Phone:727-787-3422
Practice Address - Fax:727-787-5624
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GERARDO P. SISON, JR., M.D.. P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-07
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME537252084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064334300Medicaid
FLFT979AMedicare PIN