Provider Demographics
NPI:1851477186
Name:SIDDIQUI, IMTIAZUDDIN M (MD)
Entity Type:Individual
Prefix:DR
First Name:IMTIAZUDDIN
Middle Name:M
Last Name:SIDDIQUI
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 1:252 WASHINGTON VALLEY ROAD
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869
Mailing Address - Country:US
Mailing Address - Phone:973-904-3161
Mailing Address - Fax:973-904-3163
Practice Address - Street 1:510 HAMBURG TURNPIKE
Practice Address - Street 2:SUITE E106
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470
Practice Address - Country:US
Practice Address - Phone:973-904-3161
Practice Address - Fax:973-904-3168
Is Sole Proprietor?:No
Enumeration Date:2006-10-30
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA0410782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7833008Medicaid
SI556284Medicare ID - Type Unspecified
F13374Medicare UPIN