Provider Demographics
NPI:1902893985
Name:SIDANI, JALAL K (DPM)
Entity Type:Individual
Prefix:
First Name:JALAL
Middle Name:K
Last Name:SIDANI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2563 HUNTCLIFF LN
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4902
Mailing Address - Country:US
Mailing Address - Phone:850-769-1055
Mailing Address - Fax:850-769-1434
Practice Address - Street 1:2563 HUNTCLIFF LN
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4902
Practice Address - Country:US
Practice Address - Phone:850-769-1055
Practice Address - Fax:850-769-1434
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2326213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390159900Medicaid
FL390159900Medicaid
U26976Medicare UPIN