Healthcare Provider Details

I. General information

NPI: 1902743446
Provider Name (Legal Business Name): ABDUL-WALI KASIB SIDDIQ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 LEE ROAD 974
PHENIX CITY AL
36870-6891
US

IV. Provider business mailing address

149 LEE ROAD 974
PHENIX CITY AL
36870-6891
US

V. Phone/Fax

Practice location:
  • Phone: 716-335-8502
  • Fax:
Mailing address:
  • Phone: 716-335-8502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number9633859
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: