Provider Demographics
NPI:1639119381
Name:SIDDIQUE, ISHRAT (MD)
Entity Type:Individual
Prefix:MS
First Name:ISHRAT
Middle Name:
Last Name:SIDDIQUE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2561 N 29TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-3116
Mailing Address - Country:US
Mailing Address - Phone:414-264-5338
Mailing Address - Fax:414-264-5625
Practice Address - Street 1:2561 N 29TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-3116
Practice Address - Country:US
Practice Address - Phone:414-264-5338
Practice Address - Fax:414-264-5625
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49096208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34847900Medicaid
WI34847900Medicaid