Provider Demographics
NPI:1326285875
Name:MOHAMMAD SIDDIQUE PHYSICIAN PC
Entity Type:Organization
Organization Name:MOHAMMAD SIDDIQUE PHYSICIAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIDDIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-739-4343
Mailing Address - Street 1:17020 84TH AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-2106
Mailing Address - Country:US
Mailing Address - Phone:718-739-4343
Mailing Address - Fax:718-347-6793
Practice Address - Street 1:2146 BEVERLEY RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-5406
Practice Address - Country:US
Practice Address - Phone:718-604-5402
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-20
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2131502084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100000854Medicare PIN