Provider Demographics
NPI:1346266509
Name:SIDHARTA, NATHANAEL OETOYO (M D)
Entity Type:Individual
Prefix:
First Name:NATHANAEL
Middle Name:OETOYO
Last Name:SIDHARTA
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-2301
Mailing Address - Country:US
Mailing Address - Phone:740-589-4136
Mailing Address - Fax:740-594-7604
Practice Address - Street 1:100 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-2301
Practice Address - Country:US
Practice Address - Phone:740-589-4136
Practice Address - Fax:740-594-7604
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0456542084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
E29713Medicare UPIN
OHSI0640933Medicare ID - Type Unspecified