Provider Demographics
NPI:1912048208
Name:SISSON, GARY GENE (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:GENE
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 1:2904 DIVISION STREET
Mailing Address - Street 2:
Mailing Address - City:ST JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085
Mailing Address - Country:US
Mailing Address - Phone:269-983-2020
Mailing Address - Fax:269-983-3651
Practice Address - Street 1:2904 DIVISION STREET
Practice Address - Street 2:
Practice Address - City:ST JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085
Practice Address - Country:US
Practice Address - Phone:269-983-2020
Practice Address - Fax:269-983-3651
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002192152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900A165060OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
T79414Medicare UPIN
MIA17615001Medicare PIN
MI0722790001Medicare NSC
MIC20444Medicare PIN