Provider Demographics
NPI:1538783147
Name:SISLER, MICHAEL D (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:SISLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USA MEDDAC
Mailing Address - Street 2:11050 MT. BELVEDERE BLVD
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602
Mailing Address - Country:US
Mailing Address - Phone:315-772-2020
Mailing Address - Fax:
Practice Address - Street 1:ACGME PROGRAM 1801021144 8901 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-4759
Practice Address - Country:US
Practice Address - Phone:301-295-4771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-31
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0102207184208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty