Active NPI
Clark Edmund Sisk, M.D.
- Dermatology Physician
- Portland, OR
National Provider Identifier
1154436830
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dermatology Physician
- License
- OR MD12188
- Practice address
- 3600 N Interstate Ave
Portland, OR 97227-1106 - Phone
- (503) 331-3033
- Fax
- (503) 280-2930
- NPI assigned
- Aug 20, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dermatology Physician | 207N00000X | OR MD12188 | OR | Primary |
| Dermatology Physician | 207N00000X | WA MD00035021 | WA |
Addresses
Primary practice location
3600 N Interstate Ave
Portland, OR 97227-1106
Mailing address
3600 N Interstate Ave
Kaiser, Dermatology, Central Interstate Medical Office
Portland, OR 97227-1106
Phone (503) 331-3060
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| OR MD12188 | OR | MD | Dermatology Physician |
| WA MD00035021 | WA | MD | Dermatology Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1156032000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183939200000",
"number": "1154436830",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3600 N INTERSTATE AVE",
"address_2": "KAISER, DERMATOLOGY, CENTRAL INTERSTATE MEDICAL OFFICE",
"city": "PORTLAND",
"state": "OR",
"postal_code": "972271106",
"telephone_number": "503-331-3060",
"fax_number": "503-290-2930"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3600 N INTERSTATE AVE",
"city": "PORTLAND",
"state": "OR",
"postal_code": "972271106",
"telephone_number": "503-331-3033",
"fax_number": "503-280-2930"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SISK",
"first_name": "CLARK",
"middle_name": "EDMUND",
"name_prefix": "Dr.",
"credential": "M.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-08-20",
"last_updated": "2007-07-09",
"status": "A"
},
"taxonomies": [
{
"code": "207N00000X",
"taxonomy_group": "",
"desc": "Dermatology",
"state": "OR",
"license": "OR MD12188",
"primary": true
},
{
"code": "207N00000X",
"taxonomy_group": "",
"desc": "Dermatology",
"state": "WA",
"license": "WA MD00035021",
"primary": false
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Portland, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.