Provider Demographics
NPI:1417098880
Name:SIDOROV, EVGENY VADIMOVICH (MD)
Entity Type:Individual
Prefix:
First Name:EVGENY
Middle Name:VADIMOVICH
Last Name:SIDOROV
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 1:940 STANTON L YOUNG BLVD
Mailing Address - Street 2:BMSB 357
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:711 STANTON L YOUNG BLVD
Practice Address - Street 2:PPB 215
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5023
Practice Address - Country:US
Practice Address - Phone:405-271-4113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK248942084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology