Provider Demographics
NPI:1366513426
Name:SIDDIQUI, MOHAMMED NASIRUDDIN (MD FACS)
Entity type:Individual
Prefix:DR
First Name:MOHAMMED
Middle Name:NASIRUDDIN
Last Name:SIDDIQUI
Suffix:
Gender:M
Credentials:MD FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 NEW YORK RANCH RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-9328
Mailing Address - Country:US
Mailing Address - Phone:209-257-0301
Mailing Address - Fax:209-257-0302
Practice Address - Street 1:609 NEW YORK RANCH RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-9328
Practice Address - Country:US
Practice Address - Phone:209-257-0301
Practice Address - Fax:209-257-0302
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51828208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D15171Medicare UPIN