Provider Demographics
NPI:1568751014
Name:SIDOR, PETER DAMIAN (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:DAMIAN
Last Name:SIDOR
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 1:1220 SUNSHINE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-4247
Mailing Address - Country:US
Mailing Address - Phone:307-587-5545
Mailing Address - Fax:
Practice Address - Street 1:1220 SUNSHINE AVE STE 101
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-4247
Practice Address - Country:US
Practice Address - Phone:307-587-5545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY10301A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics