Provider Demographics
NPI:1578265468
Name:SIDHU, GAGANJOT K (OD)
Entity Type:Individual
Prefix:
First Name:GAGANJOT
Middle Name:K
Last Name:SIDHU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 SUMMER LN
Mailing Address - Street 2:
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-2090
Mailing Address - Country:US
Mailing Address - Phone:510-374-0695
Mailing Address - Fax:
Practice Address - Street 1:2704 PINOLE VALLEY RD
Practice Address - Street 2:
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-1425
Practice Address - Country:US
Practice Address - Phone:510-222-6567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT35555-TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist