Provider Demographics
NPI:1285635045
Name:SIDER, TODD (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:SIDER
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 1:11141 PARKVIEW PLAZA DR STE 305
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1715
Mailing Address - Country:US
Mailing Address - Phone:260-484-9611
Mailing Address - Fax:260-484-1004
Practice Address - Street 1:2003 STULTS RD STE 120
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:IN
Practice Address - Zip Code:46750-1291
Practice Address - Country:US
Practice Address - Phone:888-633-5331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058051A2083P0011X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00116756OtherMEDICARE RAILROAD
OH2443378Medicaid
MI104575150Medicaid
IN200463170Medicaid
OH2443378Medicaid
INP00116756OtherMEDICARE RAILROAD
IN200463170Medicaid
IN667640RMedicare PIN