Healthcare Provider Details

I. General information

NPI: 1366538944
Provider Name (Legal Business Name): NIAZI RAOUF SIDHOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 NORTH HALL STREET SUITE A
VISALIA CA
93291
US

IV. Provider business mailing address

5802 W SWEET DR
VISALIA CA
93291-9297
US

V. Phone/Fax

Practice location:
  • Phone: 559-734-9669
  • Fax: 559-734-9691
Mailing address:
  • Phone: 559-734-9669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA049099
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: