Basic Information
Provider Information | |||||||||
NPI: | 1164650743 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SIDILE | ||||||||
FirstName: | JABULANI | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 680 CENTRE ST | ||||||||
Address2: |   | ||||||||
City: | BROCKTON | ||||||||
State: | MA | ||||||||
PostalCode: | 023023308 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5089417000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 680 CENTRE ST | ||||||||
Address2: |   | ||||||||
City: | BROCKTON | ||||||||
State: | MA | ||||||||
PostalCode: | 023023308 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 1508941700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2009 | ||||||||
LastUpdateDate: | 07/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01083421A | IN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RN0300X | 351223324 | OH | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | 35.123324 | OH | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 208M00000X | 35123324 | OH | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 208M00000X | 01083421A | IN | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207R00000X | 282688 | MA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.