Basic Information
| Provider Information | |||||||||
| NPI: | 1821086638 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIDHU | ||||||||
| FirstName: | UPINDERJIT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 309 SEASIDE AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | MILFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064604625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037831831 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 300 SEASIDE AVE | ||||||||
| Address2: | |||||||||
| City: | MILFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064604603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038764178 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 02/18/2014 | ||||||||
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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 | 174400000X | 028677 | CT | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 001286774 | 05 | CO | MEDICAID |