Provider Demographics
NPI:1790881704
Name:SIDOR, RICHARD JOSEPH (PT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOSEPH
Last Name:SIDOR
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21604
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-0162
Mailing Address - Country:US
Mailing Address - Phone:540-725-5300
Mailing Address - Fax:540-725-5356
Practice Address - Street 1:1919 ELECTRIC RD
Practice Address - Street 2:SUITE 1
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-1641
Practice Address - Country:US
Practice Address - Phone:540-725-5300
Practice Address - Fax:540-725-5356
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2014-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305005169225100000X
VA0104000724111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00019573Medicare PIN
VAP01310261Medicare PIN
VA00V110S45Medicare PIN
VAQ44712C13Medicare PIN
VA00V201S05Medicare PIN
VAP00019560Medicare PIN