Provider Demographics
NPI:1255616306
Name:SISSON, MATTHEW (OD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
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 1:901 NW CARLON AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-2636
Mailing Address - Country:US
Mailing Address - Phone:804-317-9401
Mailing Address - Fax:
Practice Address - Street 1:901 NW CARLON AVE STE 2
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-2636
Practice Address - Country:US
Practice Address - Phone:541-382-3242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV812152W00000X
390200000X
OR4310ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1255616306Medicaid
NVDC618AMedicare PIN