Provider Demographics
NPI:1023197241
Name:SIDIKARO, JOSEPH (MD, PH D)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:SIDIKARO
Suffix:
Gender:M
Credentials:MD, PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 N ROXBURY DR STE 410
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-5006
Mailing Address - Country:US
Mailing Address - Phone:310-858-6569
Mailing Address - Fax:310-858-3922
Practice Address - Street 1:435 N ROXBURY DR STE 410
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-5006
Practice Address - Country:US
Practice Address - Phone:310-858-6569
Practice Address - Fax:310-858-3922
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC40996207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC40996Medicare UPIN