Provider Demographics
NPI:1184852089
Name:SIDDIQUE, MOMIN SAULAT (MD)
Entity Type:Individual
Prefix:
First Name:MOMIN
Middle Name:SAULAT
Last Name:SIDDIQUE
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 1:747 N RUTLEDGE ST
Mailing Address - Street 2:PO BOX 19627
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-6700
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-7063
Practice Address - Street 1:747 N RUTLEDGE ST
Practice Address - Street 2:5TH FLOOR
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-6700
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-7063
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-137934207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036137934Medicaid
IL036137934Medicaid