Provider Demographics
NPI:1639127988
Name:SIDDIQUI, KHURRAM S (MD)
Entity Type:Individual
Prefix:
First Name:KHURRAM
Middle Name:S
Last Name:SIDDIQUI
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 N CAPITOL AVE
Practice Address - Street 2:NP E-140
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1218
Practice Address - Country:US
Practice Address - Phone:317-962-2894
Practice Address - Fax:317-963-5285
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-11-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01054953A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200387890Medicaid
IN715530R3Medicare PIN
IN267030014Medicare PIN
INH76549Medicare UPIN