Healthcare Provider Details

I. General information

NPI: 1356338388
Provider Name (Legal Business Name): JOHN R SIDDOWAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 HARRISON BLVD
OGDEN UT
84403-4303
US

IV. Provider business mailing address

PO BOX 5546
DENVER CO
80217-5546
US

V. Phone/Fax

Practice location:
  • Phone: 801-475-3075
  • Fax: 801-475-3076
Mailing address:
  • Phone: 801-475-3075
  • Fax: 801-475-3076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number185189-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: