MEDICARE: DOMENICK J SISTO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	G52313	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DA0572	OTHER	CA	RAILROAD CARRIER

General Provider Information

NPI Number	:	1568427029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMENICK J SISTO M.D.

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

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

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2006
Last Update Date	:	11/22/2011

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Directions to “ DOMENICK J SISTO M.D.” Practice Location

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