Provider Demographics
NPI:1578858155
Name:SIDDIQUI, MOHAMMAD SHADAB (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:SHADAB
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 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:1200 E. BROAD STREET
Practice Address - Street 2:WEST HOSPITAL, 14TH FLOOR
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298
Practice Address - Country:US
Practice Address - Phone:804-828-2518
Practice Address - Fax:804-828-2992
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101249953207RG0100X
VA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program