MEDICARE: JALAL K SIDANI DPM

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	213E00000X	Podiatrist	PO2326	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902893985
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JALAL K SIDANI DPM

Provider Business Mailing Address
First Line	:	2563 HUNTCLIFF LN
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4902
Country	:	US
Telephone Number	:	850-769-1055
Fax Number	:	850-769-1434

Provider Business Practice Location Address
First Line	:	2563 HUNTCLIFF LN
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4902
Country	:	US
Telephone Number	:	850-769-1055
Fax Number	:	850-769-1434

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

Provider Enumeration Date	:	10/04/2005
Last Update Date	:	05/01/2012

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