Healthcare Provider Details

I. General information

NPI: 1477600187
Provider Name (Legal Business Name): JONATHAN SIDELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 GOVERNOR CARLOS CAMACHO ROAD
OKA TAMUNING GU
96913-3128
US

IV. Provider business mailing address

850 GOVERNOR CARLOS CAMACHO ROAD
OKA TAMUNING GU
96913-3128
US

V. Phone/Fax

Practice location:
  • Phone: 671-647-2418
  • Fax: 671-649-5508
Mailing address:
  • Phone: 671-647-2418
  • Fax: 671-649-5508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberM001496
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: