Provider Demographics
NPI:1326229295
Name:SIDDIQUI, SHABANA ANJUM (MD)
Entity Type:Individual
Prefix:
First Name:SHABANA
Middle Name:ANJUM
Last Name:SIDDIQUI
Suffix:
Gender:F
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:PO BOX 2249
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91943-2249
Mailing Address - Country:US
Mailing Address - Phone:619-461-1920
Mailing Address - Fax:619-461-1919
Practice Address - Street 1:5555 GROSSMONT CENTER DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3019
Practice Address - Country:US
Practice Address - Phone:619-461-1920
Practice Address - Fax:619-461-1919
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA117648207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400009342Medicare PIN