Provider Demographics
NPI:1114033594
Name:SIDHU, RUPAL S
Entity Type:Individual
Prefix:
First Name:RUPAL
Middle Name:S
Last Name:SIDHU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7537 S RAINBOW BLVD STE 107
Mailing Address - Street 2:PMB 123
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139-0552
Mailing Address - Country:US
Mailing Address - Phone:612-703-6936
Mailing Address - Fax:
Practice Address - Street 1:7052 ORANGEWOOD AVE STE 6
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92841-1419
Practice Address - Country:US
Practice Address - Phone:714-903-1100
Practice Address - Fax:714-903-1055
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83018207Q00000X
NV10458207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2594536Medicaid
OH2594536Medicaid
OH4173421Medicare ID - Type Unspecified