Provider Demographics
NPI:1316906027
Name:SISSON, W. REYNOLDS (OD)
Entity type:Individual
Prefix:DR
First Name:W.
Middle Name:REYNOLDS
Last Name:SISSON
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 1:7 CRAMER DR
Mailing Address - Street 2:PO BOX 70
Mailing Address - City:NEWPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17074-8720
Mailing Address - Country:US
Mailing Address - Phone:717-567-3103
Mailing Address - Fax:717-567-7784
Practice Address - Street 1:7 CRAMER DR
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:PA
Practice Address - Zip Code:17074-8720
Practice Address - Country:US
Practice Address - Phone:717-567-3103
Practice Address - Fax:717-567-7784
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000258152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA288361UQ0Medicare PIN
PAU08050Medicare UPIN