Provider Demographics
NPI:1245344126
Name:SIDDIQUI, KHWAJA ALI (MD)
Entity type:Individual
Prefix:
First Name:KHWAJA
Middle Name:ALI
Last Name:SIDDIQUI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:34845 YUCAIPA BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399
Mailing Address - Country:US
Mailing Address - Phone:909-790-1837
Mailing Address - Fax:909-790-5878
Practice Address - Street 1:34845 YUCAIPA BLVD
Practice Address - Street 2:STE A
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399
Practice Address - Country:US
Practice Address - Phone:909-790-1837
Practice Address - Fax:909-790-5878
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC38594207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C385940Medicaid
00C385940Medicare ID - Type Unspecified
A36959Medicare UPIN