Provider Demographics
NPI:1508869868
Name:WANETICK, SIDNEY EVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SIDNEY
Middle Name:EVAN
Last Name:WANETICK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:7 BUTLER DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-3358
Mailing Address - Country:US
Mailing Address - Phone:925-283-9420
Mailing Address - Fax:925-283-6518
Practice Address - Street 1:19845 LAKE CHABOT RD
Practice Address - Street 2:STE 302
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-4055
Practice Address - Country:US
Practice Address - Phone:510-886-3400
Practice Address - Fax:510-886-0861
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG46693207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG46693OtherSTATE MEDICAL LICENSE
CAA50464Medicare UPIN