Provider Demographics
NPI:1265736367
Name:SIDDIQUE, MUHAMMAD TALAL (MD)
Entity type:Individual
Prefix:
First Name:MUHAMMAD
Middle Name:TALAL
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 1:6100 HARRIS PKWY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4101
Mailing Address - Country:US
Mailing Address - Phone:817-250-4906
Mailing Address - Fax:817-250-4815
Practice Address - Street 1:6100 HARRIS PKWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4101
Practice Address - Country:US
Practice Address - Phone:817-250-4906
Practice Address - Fax:817-250-4815
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP7035207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX327760003Medicaid
TX317011YKPWMedicare PIN