Provider Demographics
NPI:1609079649
Name:SIDDIQUI, SHOAIB (MD)
Entity Type:Individual
Prefix:DR
First Name:SHOAIB
Middle Name:
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 1:102 PARK PLACE BLVD. BLDG. D
Mailing Address - Street 2:SUITE 3
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-2358
Mailing Address - Country:US
Mailing Address - Phone:407-944-4900
Mailing Address - Fax:407-483-0688
Practice Address - Street 1:102 PARK PLACE BLVD. BLDG. D
Practice Address - Street 2:SUITE 3
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4213
Practice Address - Country:US
Practice Address - Phone:407-944-4900
Practice Address - Fax:407-483-0688
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75997207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL166307OtherWELLCARE
FL258319400Medicaid
FL49824OtherBCBS
FL49824ZMedicare ID - Type Unspecified
FL258319400Medicaid