Provider Demographics
NPI:1558746230
Name:SIDDIQUE, OSAMA (MD)
Entity Type:Individual
Prefix:
First Name:OSAMA
Middle Name:
Last Name:SIDDIQUE
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 1:30 WATERCHASE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-2110
Mailing Address - Country:US
Mailing Address - Phone:860-257-4131
Mailing Address - Fax:860-257-4519
Practice Address - Street 1:30 WATERCHASE DR
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067-2110
Practice Address - Country:US
Practice Address - Phone:860-257-4131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-23
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT67465207RG0100X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology