Provider Demographics
NPI:1780781781
Name:SIDO, OBUKOHWO FRANCIS (MD)
Entity type:Individual
Prefix:DR
First Name:OBUKOHWO
Middle Name:FRANCIS
Last Name:SIDO
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 1:1343 E GARRISON BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-5137
Mailing Address - Country:US
Mailing Address - Phone:704-861-9117
Mailing Address - Fax:
Practice Address - Street 1:1343 E GARRISON BLVD
Practice Address - Street 2:STE A
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5137
Practice Address - Country:US
Practice Address - Phone:704-861-9117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC87317207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC34D0977558OtherCLIA
NC76667OtherBLUE CROSS BLUE SHIELD
NC8976667Medicaid
NC9709OtherPARTNERS MEDICARE
NC2344421Medicare ID - Type UnspecifiedMEICARE PROVIDER #
NC76667OtherBLUE CROSS BLUE SHIELD
NC2199854DMedicare ID - Type Unspecified