Provider Demographics
NPI:1982848719
Name:SIDDIQUE, BUSHRA (MD)
Entity Type:Individual
Prefix:
First Name:BUSHRA
Middle Name:
Last Name:SIDDIQUE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:820 W DANFORTH RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73103-5006
Mailing Address - Country:US
Mailing Address - Phone:405-217-0203
Mailing Address - Fax:405-604-4331
Practice Address - Street 1:5401 N PORTLAND AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2121
Practice Address - Country:US
Practice Address - Phone:405-694-4966
Practice Address - Fax:405-604-4331
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK29723207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200522840AMedicaid