Provider Demographics
NPI:1558463836
Name:SIDDIQUI, ABDUL-SAMI FAWAD (MD)
Entity Type:Individual
Prefix:
First Name:ABDUL-SAMI
Middle Name:FAWAD
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 1:3540 W SAHARA AVE
Mailing Address - Street 2:SUITE 330
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-5816
Mailing Address - Country:US
Mailing Address - Phone:702-921-6823
Mailing Address - Fax:702-549-5240
Practice Address - Street 1:9300 W SUNSET RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-4844
Practice Address - Country:US
Practice Address - Phone:702-921-6823
Practice Address - Fax:702-549-5240
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8548174400000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110236074OtherRAILROAD CARRIER
NV20-02406Medicaid
NVV105400Medicare PIN
NV20-02406Medicaid