Provider Demographics
NPI:1104036631
Name:SIAHPUSH, SID H (MD, PHD MPH, CGP)
Entity Type:Individual
Prefix:
First Name:SID
Middle Name:H
Last Name:SIAHPUSH
Suffix:
Gender:M
Credentials:MD, PHD MPH, CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12025 115TH AVE NE, BUILDING D, STE 200
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-2831
Mailing Address - Country:US
Mailing Address - Phone:425-821-1810
Mailing Address - Fax:425-823-1231
Practice Address - Street 1:12025 115TH AVE NE, BUILDING D, STE 200
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-2831
Practice Address - Country:US
Practice Address - Phone:425-821-1810
Practice Address - Fax:425-823-1231
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI53335-202084P0800X
IL54654971342084P0800X
WAMD602400472084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI53335-20OtherWISCONSIN STATE LICENSE
WAMD60240047OtherWA STATE LICENSE