Provider Demographics
NPI:1598767840
Name:SIDDIQUI, SIRAJ U (MD)
Entity Type:Individual
Prefix:
First Name:SIRAJ
Middle Name:U
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 1:238 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14895-1046
Mailing Address - Country:US
Mailing Address - Phone:585-593-0400
Mailing Address - Fax:585-593-0700
Practice Address - Street 1:238 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14895-1046
Practice Address - Country:US
Practice Address - Phone:585-593-0400
Practice Address - Fax:585-593-0700
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY123278207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00604971Medicaid
NYC49534Medicare UPIN
NY00604971Medicaid