Provider Demographics
NPI:1295976330
Name:SIDDIQUE, SURAIYA (MD)
Entity type:Individual
Prefix:
First Name:SURAIYA
Middle Name:
Last Name:SIDDIQUE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 WESTPARK DR
Mailing Address - Street 2:#113
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-2565
Mailing Address - Country:US
Mailing Address - Phone:501-603-3466
Mailing Address - Fax:
Practice Address - Street 1:600 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:MO
Practice Address - Zip Code:65712-1004
Practice Address - Country:US
Practice Address - Phone:417-466-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-19
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52375-020208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice