Healthcare Provider Details

I. General information

NPI: 1255616306
Provider Name (Legal Business Name): MATTHEW SISSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 NW CARLON AVE STE 2
BEND OR
97703-2636
US

IV. Provider business mailing address

901 NW CARLON AVE STE 2
BEND OR
97703-2636
US

V. Phone/Fax

Practice location:
  • Phone: 541-382-3242
  • Fax:
Mailing address:
  • Phone: 804-317-9401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number812
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4310ATI
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: