Provider Demographics
NPI:1598941346
Name:SIUDARA, JEROME E (DO)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:E
Last Name:SIUDARA
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 1:7786 MULLETT LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CHEBOYGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49721-9056
Mailing Address - Country:US
Mailing Address - Phone:231-627-2869
Mailing Address - Fax:231-627-2869
Practice Address - Street 1:7786 MULLETT LAKE RD
Practice Address - Street 2:
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721-9056
Practice Address - Country:US
Practice Address - Phone:231-627-2869
Practice Address - Fax:231-627-2869
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-10
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJS005875207VG0400X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1651630495OtherBCBSM
MI111350021Medicaid
MI5163049Medicare PIN
MIE26180Medicare UPIN