Provider Demographics
NPI:1336301597
Name:SIDET SOU, OD, LLC
Entity Type:Organization
Organization Name:SIDET SOU, OD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SIDET
Authorized Official - Middle Name:
Authorized Official - Last Name:SOU
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:860-644-9439
Mailing Address - Street 1:69 PAVILION DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-8702
Mailing Address - Country:US
Mailing Address - Phone:860-644-9439
Mailing Address - Fax:
Practice Address - Street 1:69 PAVILION DR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-8702
Practice Address - Country:US
Practice Address - Phone:860-644-9439
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT002732152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty