Provider Demographics
NPI:1285646448
Name:SIDRANSKY, SHON MARCOS (MD)
Entity Type:Individual
Prefix:DR
First Name:SHON
Middle Name:MARCOS
Last Name:SIDRANSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1398 LA CRESCENTIA DR
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-7942
Mailing Address - Country:US
Mailing Address - Phone:619-987-5554
Mailing Address - Fax:619-271-1203
Practice Address - Street 1:1600 N ROSE AVE
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-3722
Practice Address - Country:US
Practice Address - Phone:805-988-2843
Practice Address - Fax:805-988-2844
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA91030207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A910300Medicaid
CA1285646448Medicaid
CAWA91030DMedicare PIN
CAWA91030Medicare PIN
CA1285646448Medicaid
CAWA91030CMedicare PIN
CA00A910300Medicaid
CAWA91030BMedicare PIN