Provider Demographics
NPI:1497753610
Name:SIDDIQUI, KHALID R (MD)
Entity Type:Individual
Prefix:
First Name:KHALID
Middle Name:R
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 1:1101 DECATUR ST
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-3335
Mailing Address - Country:US
Mailing Address - Phone:419-625-6647
Mailing Address - Fax:
Practice Address - Street 1:1101 DECATUR ST
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-3335
Practice Address - Country:US
Practice Address - Phone:419-625-6647
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35048385S2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0730758Medicaid
OHA15874Medicare UPIN
OH0730758Medicaid