Provider Demographics
NPI:1174907521
Name:SIDDU, MITHILESH
Entity type:Individual
Prefix:
First Name:MITHILESH
Middle Name:
Last Name:SIDDU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 POTTERY DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-9295
Mailing Address - Country:US
Mailing Address - Phone:425-894-7315
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-3201
Practice Address - Country:US
Practice Address - Phone:706-721-1962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-15
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA839922084V0102X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology