Healthcare Provider Details

I. General information

NPI: 1689317869
Provider Name (Legal Business Name): HARJINDER SINGH SIDHU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2022
Last Update Date: 07/08/2024
Certification Date: 06/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 FLORIDA AVE STE 102
MODESTO CA
95350-4446
US

IV. Provider business mailing address

232 BALD EAGLE CT
ROSEVILLE CA
95747-4918
US

V. Phone/Fax

Practice location:
  • Phone: 916-865-7030
  • Fax:
Mailing address:
  • Phone: 916-865-7030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number8805
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: