Provider Demographics
NPI:1700976073
Name:SIDDIQUE, MAHMOOD ISLAM (DO)
Entity Type:Individual
Prefix:
First Name:MAHMOOD
Middle Name:ISLAM
Last Name:SIDDIQUE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 E DARRAH LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-3763
Mailing Address - Country:US
Mailing Address - Phone:609-587-9944
Mailing Address - Fax:609-587-9955
Practice Address - Street 1:31 E DARRAH LN
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-3763
Practice Address - Country:US
Practice Address - Phone:609-587-9944
Practice Address - Fax:609-587-9955
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB05852900207RC0200X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5548608Medicaid
NJSI192610Medicare ID - Type Unspecified
NJF43060Medicare UPIN