Provider Demographics
NPI:1306397658
Name:INFECTIOUS DISEASE ASSOCIATES LLC
Entity Type:Organization
Organization Name:INFECTIOUS DISEASE ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BUSHRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-694-4966
Mailing Address - Street 1:820 W DANFORTH RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-5006
Mailing Address - Country:US
Mailing Address - Phone:405-694-4966
Mailing Address - Fax:405-604-4331
Practice Address - Street 1:5401 N PORTLAND AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2121
Practice Address - Country:US
Practice Address - Phone:405-604-4321
Practice Address - Fax:405-604-4331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK29723282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200522840AMedicaid