Provider Demographics
NPI:1972614436
Name:SIDDIQUE, SHOAB (MD)
Entity Type:Individual
Prefix:
First Name:SHOAB
Middle Name:
Last Name:SIDDIQUE
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 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3000 Q ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-7058
Practice Address - Country:US
Practice Address - Phone:916-733-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71415207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000810579445OtherPHCS
CA1837078OtherFIRST HEALTH
CA44530OtherINTERPLAN
CA7494423OtherCIGNA
CA00A714150Medicaid
CA7796146OtherAETNA
CA1294175OtherGREAT WEST
CAA71415OtherBLUE CROSS
CA079115OtherHEALTH NET
CA1968751OtherUNITED HEALTHCARE
CA90138939OtherPACIFICARE
CAMCMG298400OtherWESTERN HEALTH ADVANTAGE
CAMCMG298400OtherWESTERN HEALTH ADVANTAGE
H14985Medicare UPIN