Provider Demographics
NPI:1487617627
Name:SISE, MICHAEL J (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:SISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:550 WASHINGTON ST.
Mailing Address - Street 2:SUITE 641
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2229
Mailing Address - Country:US
Mailing Address - Phone:619-299-2600
Mailing Address - Fax:619-299-3923
Practice Address - Street 1:550 WASHINGTON ST.
Practice Address - Street 2:SUITE 641
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2229
Practice Address - Country:US
Practice Address - Phone:619-299-2600
Practice Address - Fax:619-299-3923
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG485152086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G485150Medicaid
CAF02085Medicare UPIN