Provider Demographics
NPI:1639475791
Name:DR MAHBUBUR SIDDIQUE MD LLC
Entity Type:Organization
Organization Name:DR MAHBUBUR SIDDIQUE MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAHBUBUR
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-912-0987
Mailing Address - Street 1:777 CLEMENTON BLACKWOOD ROAD
Mailing Address - Street 2:UNIT B
Mailing Address - City:LINDENWOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:08021
Mailing Address - Country:US
Mailing Address - Phone:917-912-0987
Mailing Address - Fax:
Practice Address - Street 1:777 BLACKWOOD ROAD
Practice Address - Street 2:UNIT B
Practice Address - City:LINDENWOLD
Practice Address - State:NJ
Practice Address - Zip Code:08021
Practice Address - Country:US
Practice Address - Phone:917-912-0987
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty