Provider Demographics
NPI:1013063908
Name:PANDYA, SIDDHARTH (DO)
Entity Type:Individual
Prefix:DR
First Name:SIDDHARTH
Middle Name:
Last Name:PANDYA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 NW 107TH AVE
Mailing Address - Street 2:PLANTATION
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-1524
Mailing Address - Country:US
Mailing Address - Phone:954-873-2690
Mailing Address - Fax:
Practice Address - Street 1:1100 N KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-2029
Practice Address - Country:US
Practice Address - Phone:417-256-9111
Practice Address - Fax:314-631-4672
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030282322085R0202X
FLOS91132085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOH78832Medicare UPIN