Provider Demographics
NPI:1023572252
Name:SIDDIQUI, MOIZ
Entity Type:Individual
Prefix:
First Name:MOIZ
Middle Name:
Last Name:SIDDIQUI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 OVERBROOK LN
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545-2737
Mailing Address - Country:US
Mailing Address - Phone:516-353-4451
Mailing Address - Fax:
Practice Address - Street 1:634 FULTON AVE
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-4544
Practice Address - Country:US
Practice Address - Phone:516-280-2260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY065101-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06501-1OtherSTATE LICENSE