Provider Demographics
NPI:1457430175
Name:SIDDIQUI, MOHAMMED W (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMED
Middle Name:W
Last Name:SIDDIQUI
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:PO BOX 7088
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-7088
Mailing Address - Country:US
Mailing Address - Phone:630-706-0557
Mailing Address - Fax:
Practice Address - Street 1:800 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:IL
Practice Address - Zip Code:62016-1436
Practice Address - Country:US
Practice Address - Phone:217-942-6946
Practice Address - Fax:217-942-9349
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081571207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036081571Medicaid
E64655Medicare UPIN
IL828170Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER