Basic Information
| Provider Information | |||||||||
| NPI: | 1316264286 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIDHU-BUONOCORE | ||||||||
| FirstName: | SUNITA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SIDHU | ||||||||
| OtherFirstName: | SUNITA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 79 WAWECUS ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | NORWICH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063602160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608862655 | ||||||||
| FaxNumber: | 8608879003 | ||||||||
| Practice Location | |||||||||
| Address1: | 79 WAWECUS ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | NORWICH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063602160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608862655 | ||||||||
| FaxNumber: | 8608879003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2010 | ||||||||
| LastUpdateDate: | 11/12/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 48684 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | D400021782 | 01 | MEDICARE PTAN | OTHER | P4244379 | 01 | CT | OXFORD | OTHER | P01052399 | 01 | MEDICARE RAILROAD | OTHER | 9593541 | 01 | CT | AETNA | OTHER |