Provider Demographics
NPI:1881847242
Name:PHILIP R SIDRAN, OD, PA
Entity type:Organization
Organization Name:PHILIP R SIDRAN, OD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:R
Authorized Official - Last Name:SIDRAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:305-252-7979
Mailing Address - Street 1:7971 SW 122ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-5228
Mailing Address - Country:US
Mailing Address - Phone:305-252-7979
Mailing Address - Fax:305-235-0201
Practice Address - Street 1:7971 SW 122ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-5228
Practice Address - Country:US
Practice Address - Phone:305-252-7979
Practice Address - Fax:305-235-0201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-29
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 804332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084036000Medicaid
FL084036000Medicaid
FL19015Medicare PIN