Provider Demographics
NPI:1417995259
Name:SIDDIQUE, SULTAN MAHMUD (MD)
Entity Type:Individual
Prefix:DR
First Name:SULTAN
Middle Name:MAHMUD
Last Name:SIDDIQUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:8 RICHLAND MEDICAL PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-8006
Practice Address - Country:US
Practice Address - Phone:803-434-3800
Practice Address - Fax:803-744-2759
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35596207RC0000X, 207RC0001X
PAMD069264L207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC355966Medicaid
SC355966Medicaid