Provider Demographics
NPI:1811950306
Name:SIDES, JAMES RANDALL (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:RANDALL
Last Name:SIDES
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 1:420 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21629-3055
Mailing Address - Country:US
Mailing Address - Phone:410-548-2343
Mailing Address - Fax:
Practice Address - Street 1:920 MARKET ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:MD
Practice Address - Zip Code:21629-2141
Practice Address - Country:US
Practice Address - Phone:410-479-1388
Practice Address - Fax:410-479-3007
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0031376207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD162301001Medicaid
D61604Medicare UPIN
KQ62434MMedicare ID - Type Unspecified