Provider Demographics
NPI:1083653695
Name:SIDHU, JAGDISH KAUR (ND)
Entity Type:Individual
Prefix:DR
First Name:JAGDISH
Middle Name:KAUR
Last Name:SIDHU
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 CLOSTER DOCK RD
Mailing Address - Street 2:
Mailing Address - City:CLOSTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07624-1905
Mailing Address - Country:US
Mailing Address - Phone:201-768-3900
Mailing Address - Fax:201-768-3840
Practice Address - Street 1:220 CLOSTER DOCK RD
Practice Address - Street 2:
Practice Address - City:CLOSTER
Practice Address - State:NJ
Practice Address - Zip Code:07624-1905
Practice Address - Country:US
Practice Address - Phone:201-768-3900
Practice Address - Fax:201-768-3840
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27092174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0639109Medicaid
F04146Medicare UPIN
NJ0639109Medicaid