Provider Demographics
NPI:1598766230
Name:SIDDIQ, KHALIQ (MD)
Entity Type:Individual
Prefix:
First Name:KHALIQ
Middle Name:
Last Name:SIDDIQ
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 1:279 IMPERIAL HWY
Mailing Address - Street 2:SUITE 770
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-1041
Mailing Address - Country:US
Mailing Address - Phone:714-449-4803
Mailing Address - Fax:
Practice Address - Street 1:279 IMPERIAL HWY
Practice Address - Street 2:SUITE 770
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-1041
Practice Address - Country:US
Practice Address - Phone:714-449-4803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79864207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A798640OtherMEDI- CAL
CAH92457Medicare UPIN