Provider Demographics
NPI:1770577785
Name:SIDDIQUI, NADEEM A (MD)
Entity type:Individual
Prefix:
First Name:NADEEM
Middle Name:A
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 1:1726 SHAWANO AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-3216
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:2700 E ENTERPRISE AVE,
Practice Address - Street 2:UNIT C
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913
Practice Address - Country:US
Practice Address - Phone:920-738-7300
Practice Address - Fax:920-738-7301
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35007207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33328600Medicaid
G62602Medicare UPIN