Provider Demographics
NPI:1811378979
Name:SIDDURI, NISHANTH (MD)
Entity Type:Individual
Prefix:DR
First Name:NISHANTH
Middle Name:
Last Name:SIDDURI
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 1:1412-22 FAIRMOUNT AVENUE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-2908
Mailing Address - Country:US
Mailing Address - Phone:215-684-5344
Mailing Address - Fax:215-232-4093
Practice Address - Street 1:400 W ALLEGHENY AVE STE 5B
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133-3614
Practice Address - Country:US
Practice Address - Phone:215-291-2500
Practice Address - Fax:215-291-2582
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-15
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD468294207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology