Healthcare Provider Details

I. General information

NPI: 1376031849
Provider Name (Legal Business Name): JORDAN K SISTO DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 S DOBSON RD STE 312
MESA AZ
85202-4700
US

IV. Provider business mailing address

1015 NW 22ND AVE
PORTLAND OR
97210-3025
US

V. Phone/Fax

Practice location:
  • Phone: 480-844-8218
  • Fax:
Mailing address:
  • Phone: 503-413-7361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number001051
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: