Provider Demographics
NPI:1477229995
Name:SHAFI SIDDIQI MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SHAFI SIDDIQI MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:BRIGETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-667-0817
Mailing Address - Street 1:31569 CANYON ESTATES DR STE 201
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92532-0475
Mailing Address - Country:US
Mailing Address - Phone:951-226-0866
Mailing Address - Fax:951-226-0868
Practice Address - Street 1:31569 CANYON ESTATES DR STE 201
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92532-0475
Practice Address - Country:US
Practice Address - Phone:951-226-0866
Practice Address - Fax:951-226-0868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty