Provider Demographics
NPI:1205897881
Name:SIDOROWICZ, WLADYSLAW (MD)
Entity type:Individual
Prefix:DR
First Name:WLADYSLAW
Middle Name:
Last Name:SIDOROWICZ
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 610
Mailing Address - Street 2:4 LINCOLN RD
Mailing Address - City:SOUTH FALLSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:12779
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:SOUTH FALLSBURG
Practice Address - State:NY
Practice Address - Zip Code:12779
Practice Address - Country:US
Practice Address - Phone:845-434-5858
Practice Address - Fax:845-434-5860
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1849651207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01265618Medicaid
NY01265618Medicaid
90F371Medicare ID - Type Unspecified