1710941539 NPI number — DOMENICK J SISTO M D INC

Table of content: (NPI 1710941539)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710941539 NPI number — DOMENICK J SISTO M D INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOMENICK J SISTO M D INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LOS ANGELES ORTHOPAEDIC INSTITUTE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710941539
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4955 VAN NUYS BLVD
Provider Second Line Business Mailing Address:
SUITE 615
Provider Business Mailing Address City Name:
SHERMAN OAKS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91403-1801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-905-2222
Provider Business Mailing Address Fax Number:
818-905-8702

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
38660 MEDICAL CENTER DRIVE
Provider Second Line Business Practice Location Address:
SUITE A250
Provider Business Practice Location Address City Name:
PALMDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93551-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-267-7777
Provider Business Practice Location Address Fax Number:
661-267-7101
Provider Enumeration Date:
04/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SISTO
Authorized Official First Name:
DOMENICK
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
818-905-2222

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  061942-71 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZZ36984Z . This is a "BLUE SHIELD -LANCASTER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ36983Z . This is a "BLUE SHIELD-SHERMAN OAKS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: W11945B . This is a "MEDICARE ID-VALENCIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: DA0572 . This is a "RAILROAD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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