Provider Demographics
NPI:1790473569
Name:SIDOR, GABRIEL
Entity Type:Individual
Prefix:MR
First Name:GABRIEL
Middle Name:
Last Name:SIDOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6348 SPRUCE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BEAR LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49614-9703
Mailing Address - Country:US
Mailing Address - Phone:231-383-1225
Mailing Address - Fax:
Practice Address - Street 1:6348 SPRUCE RIDGE RD
Practice Address - Street 2:
Practice Address - City:BEAR LAKE
Practice Address - State:MI
Practice Address - Zip Code:49614-9703
Practice Address - Country:US
Practice Address - Phone:231-383-1225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-28
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program