Provider Demographics
NPI:1366538944
Name:SIDHOM, NIAZI RAOUF (MD)
Entity type:Individual
Prefix:
First Name:NIAZI
Middle Name:RAOUF
Last Name:SIDHOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5802 W SWEET DR
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-9297
Mailing Address - Country:US
Mailing Address - Phone:559-734-9669
Mailing Address - Fax:
Practice Address - Street 1:107 NORTH HALL STREET
Practice Address - Street 2:SUITE A
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291
Practice Address - Country:US
Practice Address - Phone:559-734-9669
Practice Address - Fax:559-734-9691
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA049099208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF27307Medicare UPIN