Basic Information
| Provider Information | |||||||||
| NPI: | 1568666741 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIDHARTHA | ||||||||
| FirstName: | TANUJ | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2081 ARENA BLVD | ||||||||
| Address2: | 160 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958342309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9162858977 | ||||||||
| FaxNumber: | 9162850338 | ||||||||
| Practice Location | |||||||||
| Address1: | 532 OREGON ST STE 8 | ||||||||
| Address2: | |||||||||
| City: | VALLEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945903254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075541146 | ||||||||
| FaxNumber: | 7075544300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2007 | ||||||||
| LastUpdateDate: | 12/21/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | A102349 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | BP1-0018066 | 01 | INSTITUTIONAL PERMIT | OTHER |