Provider Demographics
NPI:1033265665
Name:SIDDIQUI, MOHAMMAD SHUJAUDDIN (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:SHUJAUDDIN
Last Name:SIDDIQUI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10769 HOLE AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-2808
Mailing Address - Country:US
Mailing Address - Phone:951-358-5554
Mailing Address - Fax:951-358-5980
Practice Address - Street 1:10769 HOLE AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-2808
Practice Address - Country:US
Practice Address - Phone:951-358-5554
Practice Address - Fax:951-358-5980
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63496208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics