Provider Demographics
NPI:1851969984
Name:SIDDIG, SIDDIG IZZELDIN
Entity Type:Individual
Prefix:
First Name:SIDDIG
Middle Name:IZZELDIN
Last Name:SIDDIG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 ATRIUM DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-7015
Mailing Address - Country:US
Mailing Address - Phone:469-667-1390
Mailing Address - Fax:
Practice Address - Street 1:2704 ATRIUM DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-7015
Practice Address - Country:US
Practice Address - Phone:469-667-1390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor