Provider Demographics
NPI:1336103142
Name:SIDHOM, MAGDI A (MD)
Entity Type:Individual
Prefix:DR
First Name:MAGDI
Middle Name:A
Last Name:SIDHOM
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 1:210 N TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3807
Mailing Address - Country:US
Mailing Address - Phone:800-883-7243
Mailing Address - Fax:714-647-1245
Practice Address - Street 1:9920 TALBERT AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-5153
Practice Address - Country:US
Practice Address - Phone:714-378-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA47949207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A479491Medicaid
CAGW443ZMedicare PIN
CACB211623Medicare PIN
CA050077992Medicare PIN
CAP01165297Medicare PIN
CAE73773Medicare UPIN
CAA47949AMedicare PIN