MEDICARE: DR. SIDNEY EVAN WANETICK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VG0400X	Gynecology Physician	G46693	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G46693	OTHER	CA	STATE MEDICAL LICENSE

General Provider Information

NPI Number	:	1508869868
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SIDNEY EVAN WANETICK MD

Provider Business Mailing Address
First Line	:	7 BUTLER DR
Second Line	:
City	:	LAFAYETTE
State	:	CA
Zip	:	94549-3358
Country	:	US
Telephone Number	:	925-283-9420
Fax Number	:	925-283-6518

Provider Business Practice Location Address
First Line	:	19845 LAKE CHABOT RD
Second Line	:	STE 302
City	:	CASTRO VALLEY
State	:	CA
Zip	:	94546-4055
Country	:	US
Telephone Number	:	510-886-3400
Fax Number	:	510-886-0861

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	07/08/2007

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