Healthcare Provider Details

I. General information

NPI: 1710941539
Provider Name (Legal Business Name): DOMENICK J SISTO M D INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38660 MEDICAL CENTER DRIVE SUITE A250
PALMDALE CA
93551-0000
US

IV. Provider business mailing address

4955 VAN NUYS BLVD SUITE 615
SHERMAN OAKS CA
91403-1801
US

V. Phone/Fax

Practice location:
  • Phone: 661-267-7777
  • Fax: 661-267-7101
Mailing address:
  • Phone: 818-905-2222
  • Fax: 818-905-8702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number061942-71
License Number StateCA

VIII. Authorized Official

Name: DOMENICK J SISTO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 818-905-2222