Healthcare Provider Details

I. General information

NPI: 1174907521
Provider Name (Legal Business Name): MITHILESH SIDDU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2015
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-3201
US

IV. Provider business mailing address

409 POTTERY DR
MARTINEZ GA
30907-9295
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-1962
  • Fax:
Mailing address:
  • Phone: 425-894-7315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number83992
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number83992
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: