Provider Demographics
NPI:1164955936
Name:SIDDIQUE, SHEHZAD HASSAN
Entity Type:Individual
Prefix:
First Name:SHEHZAD
Middle Name:HASSAN
Last Name:SIDDIQUE
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 1:240 N TILLOTSON AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-3988
Mailing Address - Country:US
Mailing Address - Phone:765-288-1928
Mailing Address - Fax:
Practice Address - Street 1:3620 W WHITE RIVER BLVD
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-4286
Practice Address - Country:US
Practice Address - Phone:765-288-1928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01084995A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry