Provider Demographics
NPI:1992766208
Name:SIDRAN, PHILIP ROSS (OD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:ROSS
Last Name:SIDRAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7971 SW 122ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-5228
Mailing Address - Country:US
Mailing Address - Phone:305-252-7979
Mailing Address - Fax:305-235-0201
Practice Address - Street 1:7971 SW 122ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-5228
Practice Address - Country:US
Practice Address - Phone:305-252-7979
Practice Address - Fax:305-235-0201
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC804152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084036000Medicaid
FL19015Medicare PIN
FLT83952Medicare UPIN
FL084036000Medicaid