Provider Demographics
NPI:1568742666
Name:SIDDIQUI, MOHAMAD ZIA (DO)
Entity Type:Individual
Prefix:MR
First Name:MOHAMAD
Middle Name:ZIA
Last Name:SIDDIQUI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5870 N HIATUS RD
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-6424
Mailing Address - Country:US
Mailing Address - Phone:888-447-2362
Mailing Address - Fax:865-560-7110
Practice Address - Street 1:6451 BRENTWOOD STAIR RD STE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-3200
Practice Address - Country:US
Practice Address - Phone:972-249-0206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY278779207Q00000X
NY278779-1208M00000X
TXS2509207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04349060Medicaid
NYA400137974Medicare PIN