Provider Demographics
NPI:1679657860
Name:SIDDIQUI, SHANTI (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANTI
Middle Name:
Last Name:SIDDIQUI
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 1:609 NEW YORK RANCH RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-9328
Mailing Address - Country:US
Mailing Address - Phone:209-257-0311
Mailing Address - Fax:209-257-0302
Practice Address - Street 1:609 NEW YORK RANCH RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-9328
Practice Address - Country:US
Practice Address - Phone:209-257-0311
Practice Address - Fax:209-257-0302
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51834207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C518340Medicaid
ZZZ325042Medicare ID - Type Unspecified
CA00C518340Medicaid