Provider Demographics
NPI:1619933728
Name:SIDDIQUE, IRFAN (MD)
Entity Type:Individual
Prefix:
First Name:IRFAN
Middle Name:
Last Name:SIDDIQUE
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 3230
Mailing Address - Street 2:SUITE 312
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-3230
Mailing Address - Country:US
Mailing Address - Phone:407-909-1492
Mailing Address - Fax:
Practice Address - Street 1:720 W OAK ST
Practice Address - Street 2:SUITE 312
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4989
Practice Address - Country:US
Practice Address - Phone:407-944-1800
Practice Address - Fax:407-944-9377
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2016-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 0070992207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL250988100Medicaid
FLG 37586Medicare UPIN
FL250988100Medicaid