Provider Demographics
NPI:1740284413
Name:SIDIQ, MOHAMMAD (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:SIDIQ
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 1:745 HASKINS RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-1637
Mailing Address - Country:US
Mailing Address - Phone:419-353-7069
Mailing Address - Fax:419-353-7076
Practice Address - Street 1:1039 HASKINS RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-9065
Practice Address - Country:US
Practice Address - Phone:419-352-1121
Practice Address - Fax:419-352-1179
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35034291S207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0183626Medicaid
OHDA5101OtherRR MEDICARE
OHSI0374083Medicare ID - Type Unspecified
OHD31915Medicare UPIN