Basic Information
| Provider Information | |||||||||
| NPI: | 1144228255 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIDES | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | MITCHELL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30077 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841300077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024770772 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 688 KINOOLE ST | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | HILO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8089351825 | ||||||||
| FaxNumber: | 9036637394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 11/08/2018 | ||||||||
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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 | 2085R0202X | G76456 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | G76456 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | 10716 | NV | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 905838 | 05 | AZ | MEDICAID | CC5535 | 01 | NV | BLUE | OTHER | 100502411 | 05 | NV | MEDICAID |