Provider Demographics
NPI:1477533396
Name:SIDDIQUI, PERVEZ A (MD)
Entity Type:Individual
Prefix:DR
First Name:PERVEZ
Middle Name:A
Last Name:SIDDIQUI
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 1:9045 LA FONTANA BLVD STE 225
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33434-5643
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9045 LA FONTANA BLVD STE 225
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33434-5643
Practice Address - Country:US
Practice Address - Phone:561-314-5377
Practice Address - Fax:561-892-3868
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR01302085R0202X
FL893992085R0202X, 363AM0700X
IN01082784A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268692900Medicaid
FL37760XMedicare ID - Type Unspecified
FL37760AMedicare ID - Type Unspecified
FL268692900Medicaid
FL37760YMedicare ID - Type Unspecified