Provider Demographics
NPI:1144409673
Name:SIRAJ A SIDDIQUI, MD
Entity Type:Organization
Organization Name:SIRAJ A SIDDIQUI, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SIRAJ
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-774-9993
Mailing Address - Street 1:1613 HIDDEN OAK TRL
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-3558
Mailing Address - Country:US
Mailing Address - Phone:419-774-9993
Mailing Address - Fax:
Practice Address - Street 1:216 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CRESTLINE
Practice Address - State:OH
Practice Address - Zip Code:44827-1431
Practice Address - Country:US
Practice Address - Phone:419-683-8041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35065056S207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000140397OtherANTHEM
OH0954347Medicaid
OH000000140397OtherANTHEM