Provider Demographics
NPI:1962758698
Name:SIDAROS, RAFIK (MD)
Entity type:Individual
Prefix:DR
First Name:RAFIK
Middle Name:
Last Name:SIDAROS
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 1:2039 FOREST AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-4815
Mailing Address - Country:US
Mailing Address - Phone:408-358-8090
Mailing Address - Fax:
Practice Address - Street 1:34 PARK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1109
Practice Address - Country:US
Practice Address - Phone:203-974-7169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-31
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA1731562084F0202X
CT548192084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic PsychiatryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program