Provider Demographics
NPI:1659843753
Name:SIUDA, JOSEPH (LAC)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:
Last Name:SIUDA
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 1ST ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4112
Mailing Address - Country:US
Mailing Address - Phone:208-403-2540
Mailing Address - Fax:
Practice Address - Street 1:1421 1ST ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4112
Practice Address - Country:US
Practice Address - Phone:208-403-2540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-30
Last Update Date:2018-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACU-197171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist