Healthcare Provider Details

I. General information

NPI: 1194098111
Provider Name (Legal Business Name): JEREMIAH SISAY PHARMD, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2012
Last Update Date: 03/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2698 N GALLOWAY AVE STE 101
MESQUITE TX
75150
US

IV. Provider business mailing address

2698 N GALLOWAY AVE STE 101
MESQUITE TX
75150-6384
US

V. Phone/Fax

Practice location:
  • Phone: 972-288-1662
  • Fax:
Mailing address:
  • Phone: 940-442-5209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1-13931
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR1649
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: