Provider Demographics
NPI:1407826993
Name:SIDDENS, JOHN DELMAR (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DELMAR
Last Name:SIDDENS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:104 SIMPSON STREET
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-3593
Practice Address - Country:US
Practice Address - Phone:864-522-3900
Practice Address - Fax:864-522-3909
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC291207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC180018447OtherMEDICARE RAILROAD
SC2556148003OtherCIGNA PROVIDER NUMBER
SC4232647OtherAETNA PROVIDER NUMBER
SCTL0727Medicaid
SCE496774589Medicare PIN
SC4232647OtherAETNA PROVIDER NUMBER
SCTL0727Medicaid