Provider Demographics
NPI:1518999333
Name:SIDDIQUI, SIRAJ A (MD)
Entity Type:Individual
Prefix:
First Name:SIRAJ
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:PO BOX 3804
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907-3804
Mailing Address - Country:US
Mailing Address - Phone:419-884-7232
Mailing Address - Fax:
Practice Address - Street 1:2666 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44904-1428
Practice Address - Country:US
Practice Address - Phone:419-884-7232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35065056207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000140397OtherANTHEM
OH0954347Medicaid
OH0954347Medicaid