Provider Demographics
NPI:1235190315
Name:SIDDIQUI, MOHAMMAD M (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:M
Last Name:SIDDIQUI
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 1:479 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HOLLISTON
Mailing Address - State:MA
Mailing Address - Zip Code:01746
Mailing Address - Country:US
Mailing Address - Phone:508-429-2377
Mailing Address - Fax:508-429-2607
Practice Address - Street 1:479 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HOLLISTON
Practice Address - State:MA
Practice Address - Zip Code:01746
Practice Address - Country:US
Practice Address - Phone:508-429-2377
Practice Address - Fax:508-429-2607
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA71839207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2059657Medicaid
B96902Medicare UPIN
SIB20017Medicare ID - Type Unspecified