Provider Demographics
NPI:1972569515
Name:SIDORIAK, PETER P (DPM)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:P
Last Name:SIDORIAK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1851 WEST END AVE
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-2050
Mailing Address - Country:US
Mailing Address - Phone:570-622-3668
Mailing Address - Fax:570-622-2920
Practice Address - Street 1:1851 WEST END AVE
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-2050
Practice Address - Country:US
Practice Address - Phone:570-622-3668
Practice Address - Fax:570-622-2920
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-22
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002367L213E00000X
FLPO0001394213E00000X
AZ0200213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017120040001Medicaid
PA0017120040001Medicaid
187101Medicare ID - Type Unspecified
PA0485860001Medicare NSC