Healthcare Provider Details

I. General information

NPI: 1508020918
Provider Name (Legal Business Name): RICHARD B SISSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2008
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 LOISDALE CT FL 7
SPRINGFIELD VA
22150-1826
US

IV. Provider business mailing address

6501 LOISDALE CT FL 7
SPRINGFIELD VA
22150-1826
US

V. Phone/Fax

Practice location:
  • Phone: 703-922-1152
  • Fax:
Mailing address:
  • Phone: 703-922-1152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0101264197
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberDR46752
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: