Healthcare Provider Details

I. General information

NPI: 1518149467
Provider Name (Legal Business Name): IGOR SISTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2007
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR
SAN DIEGO CA
92103-9000
US

IV. Provider business mailing address

911 NORTHLAND DR
PRINCETON MN
55371-2172
US

V. Phone/Fax

Practice location:
  • Phone: 800-926-8273
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC164561
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number32872
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number74296
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number40933
License Number StateOK
# 5
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number164561
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License NumberC164561
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: