Provider Demographics
NPI:1528090586
Name:SIDWA, ROBERT M (DO)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:SIDWA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 S EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-2739
Mailing Address - Country:US
Mailing Address - Phone:856-686-4300
Mailing Address - Fax:
Practice Address - Street 1:18 E LAUREL RD
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1327
Practice Address - Country:US
Practice Address - Phone:856-345-6715
Practice Address - Fax:756-346-6385
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB63506207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7578300Medicaid
G67006Medicare UPIN
NJ7578300Medicaid