Provider Demographics
NPI:1366414864
Name:SIDDIQUI, SAMEER A (MD)
Entity type:Individual
Prefix:
First Name:SAMEER
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 1:1008 S SPRING AVE RM 1311
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2520
Mailing Address - Country:US
Mailing Address - Phone:314-977-3626
Mailing Address - Fax:
Practice Address - Street 1:1201 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1016
Practice Address - Country:US
Practice Address - Phone:314-977-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009034594208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN609930100Medicaid
MNP00052041Medicare ID - Type UnspecifiedRAILROAD
MN609930100Medicaid
MN340000781Medicare ID - Type Unspecified