| National Provider Identifier [NPI]: | 1790731776 |
| Last Name Of The Provider | SIDARTA |
| First Name Of The Provider | ANGELIA |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 500 W CENTRAL AVE |
| Street Address 2 Of The Provider | SUITE B |
| City Of The Provider | BREA |
| Zip Code Of The Provider | 928213027 |
| State Code Of The Provider | CA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 44 |
| Number Of Services | 539 |
| Number Of Medicare Beneficiaries | 95 |
| Total Submitted Charge Amount | 54750 |
| Total Medicare Allowed Amount | 38798.31 |
| Total Medicare Payment Amount | 27731.33 |
| Total Medicare Standardized Payment Amount | 24642.27 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 8 |
| Number Of Drug Services | 73 |
| Number Of Medicare Beneficiaries With Drug Services | 25 |
| Total Drug Submitted ChargeAmount | 1689 |
| Total Drug Medicare AllowedAmount | 442.48 |
| Total Drug Medicare PaymentAmount | 403.64 |
| Total Drug Medicare Standardized Payment Amount | 403.64 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 36 |
| Number Of Medical Services | 466 |
| Number Of Medicare Beneficiaries With Medical Services | 95 |
| Total Medical Submitted Charge Amount | 53061 |
| Total Medical Medicare Allowed Amount | 38355.83 |
| Total Medical Medicare Payment Amount | 27327.69 |
| Total Medical Medicare Standardized Payment Amount | 24238.63 |
| Average Age Of Beneficiaries | 74 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 41 |
| Number Of Beneficiaries Age 75 to 84 | 31 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 65 |
| Number Of Male Beneficiaries | 30 |
| Number Of Non Hispanic White Beneficiaries | 73 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 84 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 11 |
| Percent Of With Atrial Fibrillation | 13 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 15 |
| Percent Of With Chronic Kidney Disease | 28 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 12 |
| Percent Of With Depression | 18 |
| Percent Of With Diabetes | 22 |
| Percent Of With Hyperlipidemia | 57 |
| Percent Of With Hypertension | 57 |
| Percent Of With Ischemic Heart Disease | 26 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 36 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 0 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.2067 |