Healthcare Provider Details

I. General information

NPI: 1851301220
Provider Name (Legal Business Name): IBRAHIM WILLIAM SIDHOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 PULASKI AVE
CARTERET NJ
07008-2509
US

IV. Provider business mailing address

48 PULASKI AVE
CARTERET NJ
07008-2509
US

V. Phone/Fax

Practice location:
  • Phone: 732-541-5595
  • Fax: 732-541-1451
Mailing address:
  • Phone: 732-541-5595
  • Fax: 732-541-1451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMA50525
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: