MEDICARE: ERNEST E. SISNEROS JR. O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	S-B01-TA-673	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	S-B01-TA-673	OTHER	AL	AL BOARD OF OPTOMETRY

General Provider Information

NPI Number	:	1619942612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERNEST E. SISNEROS JR. O.D.

Provider Business Mailing Address
First Line	:	1950 OLD GALLOWS RD STE 520
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22182-3970
Country	:	US
Telephone Number	:	703-847-8899
Fax Number	:	571-223-6780

Provider Business Practice Location Address
First Line	:	2550 EASTERN BLVD
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36117-1500
Country	:	US
Telephone Number	:	334-274-2020
Fax Number	:	334-396-9924

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2006
Last Update Date	:	03/07/2023

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