Provider Demographics
NPI:1407027444
Name:SHANTI SIDDIQUI, M.D. A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SHANTI SIDDIQUI, M.D. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANTI
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-257-0311
Mailing Address - Street 1:609 NEW YORK RANCH RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-9328
Mailing Address - Country:US
Mailing Address - Phone:209-257-0311
Mailing Address - Fax:209-257-0302
Practice Address - Street 1:609 NEW YORK RANCH RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-9328
Practice Address - Country:US
Practice Address - Phone:209-257-0311
Practice Address - Fax:209-257-0302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC-51834174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ32504ZMedicare PIN
CAZZZ32504ZMedicare UPIN