Provider Demographics
NPI:1649358722
Name:SIDHU, JASPAL S (MD)
Entity type:Individual
Prefix:
First Name:JASPAL
Middle Name:S
Last Name:SIDHU
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 1:1800 HARRISON ST FL 7
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3429
Mailing Address - Country:US
Mailing Address - Phone:510-625-6262
Mailing Address - Fax:
Practice Address - Street 1:3400 DELTA FAIR BLVD
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-4004
Practice Address - Country:US
Practice Address - Phone:925-779-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC503232083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C503230Medicaid
00C503230Medicare ID - Type Unspecified
CA00C503230Medicaid