Provider Demographics
NPI:1700888187
Name:SIDDIQUE, IRSHAD AHMED (DPM)
Entity Type:Individual
Prefix:DR
First Name:IRSHAD
Middle Name:AHMED
Last Name:SIDDIQUE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:HARVARD
Mailing Address - State:IL
Mailing Address - Zip Code:60033-3061
Mailing Address - Country:US
Mailing Address - Phone:815-943-7709
Mailing Address - Fax:847-931-7726
Practice Address - Street 1:400 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:HARVARD
Practice Address - State:IL
Practice Address - Zip Code:60033-3061
Practice Address - Country:US
Practice Address - Phone:815-943-7709
Practice Address - Fax:847-931-7726
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2007-11-12
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0005632037OtherBLUECROSS BLUESHIELD
IL0005632037OtherBLUECROSS BLUESHIELD
T91704Medicare UPIN
ILK27766Medicare PIN