Provider Demographics
NPI:1366428914
Name:SIDES, STEPHEN D (DO)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:D
Last Name:SIDES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 104240
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4240
Mailing Address - Country:US
Mailing Address - Phone:573-635-5264
Mailing Address - Fax:573-761-4351
Practice Address - Street 1:1241 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6023
Practice Address - Country:US
Practice Address - Phone:573-635-5264
Practice Address - Fax:573-761-4351
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001001591207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00143530OtherMEDICARE RAILROAD
MOCD6058OtherRAILROAD GROUP
MO245300611Medicaid
MO191077OtherBCBS
MO461803OtherHEALTHLINK
MO245300611Medicaid
MO191077OtherBCBS