Provider Demographics
NPI:1285685446
Name:SIDDIQUE, MOHAMED S (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMED
Middle Name:S
Last Name:SIDDIQUE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:17177 N LAUREL PARK DR
Mailing Address - Street 2:STE 439
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-3938
Mailing Address - Country:US
Mailing Address - Phone:248-354-4709
Mailing Address - Fax:248-354-4807
Practice Address - Street 1:27207 LAHSER RD
Practice Address - Street 2:STE 200B
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-8407
Practice Address - Country:US
Practice Address - Phone:248-354-4709
Practice Address - Fax:248-354-4807
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2016-02-22
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Provider Licenses
StateLicense IDTaxonomies
MIMS044111207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104722864Medicaid
MI104722864Medicaid
MIB48981Medicare UPIN