Basic Information
| Provider Information | |||||||||
| NPI: | 1508869868 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WANETICK | ||||||||
| FirstName: | SIDNEY | ||||||||
| MiddleName: | EVAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 BUTLER DR | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945493358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252839420 | ||||||||
| FaxNumber: | 9252836518 | ||||||||
| Practice Location | |||||||||
| Address1: | 19845 LAKE CHABOT RD | ||||||||
| Address2: | STE 302 | ||||||||
| City: | CASTRO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945464055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108863400 | ||||||||
| FaxNumber: | 5108860861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | G46693 | CA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | G46693 | 01 | CA | STATE MEDICAL LICENSE | OTHER |