Provider Demographics
NPI:1912491200
Name:SIDDIQUE, ATIF AHMED (DO)
Entity Type:Individual
Prefix:
First Name:ATIF
Middle Name:AHMED
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 1:1205 LAKE CHARLES CIR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-4718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3305 US HIGHWAY 98 S
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-8365
Practice Address - Country:US
Practice Address - Phone:863-777-2740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOS18123207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program