Provider Demographics
NPI:1912056318
Name:SIDDIQI, SIRAJ U (MD)
Entity Type:Individual
Prefix:
First Name:SIRAJ
Middle Name:U
Last Name:SIDDIQI
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 1:2700 STANLEY GAULT PKWY STE 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:502-253-4900
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:1019 COMMERCE PKWY
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-8779
Practice Address - Country:US
Practice Address - Phone:502-225-9098
Practice Address - Fax:502-225-9851
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28062207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000052106OtherANTHEM
KY64280621Medicaid
KY000000052106OtherANTHEM
KY1747401Medicare PIN
KY110178408Medicare PIN