Provider Demographics
NPI:1891989075
Name:SIDHOM, VICTOR (MD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:
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:PO BOX 601082
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1082
Mailing Address - Country:US
Mailing Address - Phone:864-885-7989
Mailing Address - Fax:864-885-7867
Practice Address - Street 1:298 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-9443
Practice Address - Country:US
Practice Address - Phone:864-885-7758
Practice Address - Fax:864-885-7749
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD432624207R00000X, 208M00000X
SC31567208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4697OtherMEDICAID GROUP
SC8768OtherMEDICARE GROUP
SCGP5247Medicaid
SCAA44399342Medicare PIN