Provider Demographics
NPI:1073184933
Name:SIDDEEK, ESRA (DO)
Entity Type:Individual
Prefix:DR
First Name:ESRA
Middle Name:
Last Name:SIDDEEK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-1443
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 S OSTEOPATHY AVE
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-6401
Practice Address - Country:US
Practice Address - Phone:660-785-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-01
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021021665204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty