Provider Demographics
NPI:1811737414
Name:GILL, SIDRA
Entity type:Individual
Prefix:
First Name:SIDRA
Middle Name:
Last Name:GILL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E CRESCENT AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER SADDLE RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07458-1846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4646 FAIRPORT NINE MILE PT RD
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-1163
Practice Address - Country:US
Practice Address - Phone:302-233-5660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY60-P128130-01207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine