Provider Demographics
NPI:1164410403
Name:SADIQ, MOHAMED HABIBULLA (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMED
Middle Name:HABIBULLA
Last Name:SADIQ
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 1:620 EAST MEDICAL DRIVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-5085
Mailing Address - Country:US
Mailing Address - Phone:801-298-4112
Mailing Address - Fax:801-298-5397
Practice Address - Street 1:620 EAST MEDICAL DRIVE
Practice Address - Street 2:SUITE 150
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-5085
Practice Address - Country:US
Practice Address - Phone:801-298-4112
Practice Address - Fax:801-298-5397
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4966884-12052084N0600X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT77861239003Medicaid
UTH78630Medicare UPIN
UT005718201Medicare PIN
000062448Medicare PIN
UT77861239003Medicaid