Healthcare Provider Details

I. General information

NPI: 1093165953
Provider Name (Legal Business Name): KEVIN SIDHU DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12140 NEW YORK RANCH RD
JACKSON CA
95642-9407
US

IV. Provider business mailing address

2362 CAMBERWELL DR
SAINT LOUIS MO
63131-2116
US

V. Phone/Fax

Practice location:
  • Phone: 209-257-2400
  • Fax:
Mailing address:
  • Phone: 209-269-0451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A15886
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036158817
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2019045209
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: