Healthcare Provider Details

I. General information

NPI: 1457489429
Provider Name (Legal Business Name): JAMIE DON SISK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 05/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 S 12TH AVE
LAUREL MS
39440-4324
US

IV. Provider business mailing address

203 S 12TH AVE
LAUREL MS
39440-4324
US

V. Phone/Fax

Practice location:
  • Phone: 601-649-9706
  • Fax: 601-649-9708
Mailing address:
  • Phone: 601-649-9706
  • Fax: 601-649-9708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number18509
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: