Provider Demographics
NPI:1316060569
Name:SISTICK, MICHAEL JOSEPH (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:SISTICK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4288 BALDWIN RD
Mailing Address - Street 2:
Mailing Address - City:AUBURN HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48326-1268
Mailing Address - Country:US
Mailing Address - Phone:248-253-0900
Mailing Address - Fax:248-332-4952
Practice Address - Street 1:4288 BALDWIN RD
Practice Address - Street 2:
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-1268
Practice Address - Country:US
Practice Address - Phone:248-253-0900
Practice Address - Fax:248-332-4952
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003598152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
110955OtherEYE MED
900E06513OtherBCBS
MI3404800Medicaid
0552080001Medicare ID - Type Unspecified
U77979Medicare UPIN
MIN26930140Medicare PIN