Provider Demographics
NPI:1770553851
Name:SIADY, JESUS C (MD)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:C
Last Name:SIADY
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 1:901 WESTLAKE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:KY
Mailing Address - Zip Code:42728-1123
Mailing Address - Country:US
Mailing Address - Phone:270-384-4753
Mailing Address - Fax:270-385-9123
Practice Address - Street 1:198 CREEKPORT DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:KY
Practice Address - Zip Code:42728-2120
Practice Address - Country:US
Practice Address - Phone:270-250-9428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY26032207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64260326Medicaid
KY64260326Medicaid