Provider Demographics
NPI:1649238148
Name:SIDHOM, OSAMA A (MD)
Entity Type:Individual
Prefix:
First Name:OSAMA
Middle Name:A
Last Name:SIDHOM
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 1:1135 S SUNSET AVE STE 405
Mailing Address - Street 2:
Mailing Address - City:WEST CORINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790
Mailing Address - Country:US
Mailing Address - Phone:626-960-2326
Mailing Address - Fax:626-960-9796
Practice Address - Street 1:1135 S SUNSET AVE STE 405
Practice Address - Street 2:
Practice Address - City:WEST CORINA
Practice Address - State:CA
Practice Address - Zip Code:91790
Practice Address - Country:US
Practice Address - Phone:626-960-2326
Practice Address - Fax:626-960-9796
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50986207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F84990Medicare UPIN
WA50986BMedicare ID - Type Unspecified