Provider Demographics
NPI:1295784734
Name:SIDWA, CHARLES (PA)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:SIDWA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 LAKEWOOD RD STE 16
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-3287
Mailing Address - Country:US
Mailing Address - Phone:732-456-7777
Mailing Address - Fax:848-251-2189
Practice Address - Street 1:1322 ROUTE 72 W
Practice Address - Street 2:SUITE 201
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050
Practice Address - Country:US
Practice Address - Phone:800-337-6663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00052400207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ320562OtherAMERICAID/AMERIGROUP
NJ3K3524OtherHEALTHNET
NJ3K3524OtherHEALTHNET
NJP00904Medicare UPIN