Provider Demographics
NPI:1174087662
Name:SIDHU, GURSHARN SINGH (RADT)
Entity type:Individual
Prefix:
First Name:GURSHARN
Middle Name:SINGH
Last Name:SIDHU
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:GARY
Other - Middle Name:
Other - Last Name:SIDHU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RADT
Mailing Address - Street 1:160 E VIRGINIA ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-5865
Mailing Address - Country:US
Mailing Address - Phone:408-918-2618
Mailing Address - Fax:408-579-6131
Practice Address - Street 1:160 E VIRGINIA ST STE 100
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-5865
Practice Address - Country:US
Practice Address - Phone:408-918-2618
Practice Address - Fax:408-579-6131
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1322710918171M00000X
CARH0011500923101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator