Provider Demographics
NPI:1780682906
Name:SIDDIQI, AMANULLAH (MD)
Entity Type:Individual
Prefix:
First Name:AMANULLAH
Middle Name:
Last Name:SIDDIQI
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 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:1285 HIGHWAY 11W
Practice Address - Street 2:
Practice Address - City:BEAN STATION
Practice Address - State:TN
Practice Address - Zip Code:37708
Practice Address - Country:US
Practice Address - Phone:865-993-4300
Practice Address - Fax:865-993-4304
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD27361207P00000X, 208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3097419Medicaid
G01332Medicare UPIN
TN3097419Medicaid