Provider Demographics
NPI:1255343695
Name:SIDDOWAY, FRANK A (OD)
Entity type:Individual
Prefix:DR
First Name:FRANK
Middle Name:A
Last Name:SIDDOWAY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 N 200 W
Mailing Address - Street 2:#11- A
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-2540
Mailing Address - Country:US
Mailing Address - Phone:801-374-2227
Mailing Address - Fax:801-374-5197
Practice Address - Street 1:1675 N 200 W
Practice Address - Street 2:#11- A
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-2540
Practice Address - Country:US
Practice Address - Phone:801-374-2227
Practice Address - Fax:801-374-5197
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT112569-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTT78178Medicare UPIN
UT005749501Medicare PIN