Provider Demographics
NPI:1467763078
Name:SIDDIQ, ASIF (MD)
Entity Type:Individual
Prefix:DR
First Name:ASIF
Middle Name:
Last Name:SIDDIQ
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 1:1234 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-3329
Mailing Address - Country:US
Mailing Address - Phone:909-596-4879
Mailing Address - Fax:909-596-9199
Practice Address - Street 1:1234 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-3329
Practice Address - Country:US
Practice Address - Phone:909-596-4879
Practice Address - Fax:909-596-9199
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116022902207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine