Provider Demographics
NPI:1841514049
Name:SICKINGER, MARYAM (DO)
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:SICKINGER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41990 COOK ST BLDG F1006
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-6100
Mailing Address - Country:US
Mailing Address - Phone:760-568-9300
Mailing Address - Fax:760-568-9331
Practice Address - Street 1:41990 COOK ST BLDG F1006
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-6100
Practice Address - Country:US
Practice Address - Phone:760-568-9300
Practice Address - Fax:760-568-9331
Is Sole Proprietor?:No
Enumeration Date:2010-03-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A10108207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A10108OtherMEDICAL LICENSE
CA20A10108OtherMEDICAL LICENSE