Provider Demographics
NPI:1174580898
Name:SIDEBOTTOM, DAVID G (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:G
Last Name:SIDEBOTTOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:11 OUTLOOK RD
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-1415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:275 VARNUM AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854-2109
Practice Address - Country:US
Practice Address - Phone:978-934-9220
Practice Address - Fax:978-453-7771
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA48047207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3003191Medicaid
MAJ04569Medicare PIN
MA3003191Medicaid