Provider Demographics
NPI:1144228255
Name:SIDES, DOUGLAS MITCHELL (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:MITCHELL
Last Name:SIDES
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:PO BOX 30077
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0077
Mailing Address - Country:US
Mailing Address - Phone:702-477-0772
Mailing Address - Fax:
Practice Address - Street 1:688 KINOOLE ST
Practice Address - Street 2:SUITE 103
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720
Practice Address - Country:US
Practice Address - Phone:808-935-1825
Practice Address - Fax:903-663-7394
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG764562085R0202X, 2085R0204X
NV107162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ905838Medicaid
NVCC5535OtherBLUE
NV100502411Medicaid
NV100502411Medicaid
NV38620Medicare ID - Type Unspecified
G38881Medicare UPIN
NVP00125187Medicare ID - Type Unspecified
NVCC5535OtherBLUE
AZ905838Medicaid
NVP00299805Medicare PIN