Provider Demographics
NPI:1114932746
Name:SIDANI, SAMIR (MD)
Entity Type:Individual
Prefix:
First Name:SAMIR
Middle Name:
Last Name:SIDANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1890 PALMER AVE
Mailing Address - Street 2:SUITE # 304
Mailing Address - City:LARCHMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10538-3059
Mailing Address - Country:US
Mailing Address - Phone:914-834-4123
Mailing Address - Fax:914-834-5275
Practice Address - Street 1:1890 PALMER AVE
Practice Address - Street 2:SUITE # 304
Practice Address - City:LARCHMONT
Practice Address - State:NY
Practice Address - Zip Code:10538-3059
Practice Address - Country:US
Practice Address - Phone:914-834-4123
Practice Address - Fax:914-834-5275
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197234207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF51875Medicare UPIN
NYOD4121Medicare ID - Type Unspecified