Healthcare Provider Details

I. General information

NPI: 1649470071
Provider Name (Legal Business Name): IBRAHIM H SIDIQI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2007
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805 E BELL RD SUITE 3100
PHOENIX AZ
85032-2105
US

IV. Provider business mailing address

3805 E BELL RD STE 3100
PHOENIX AZ
85032-2136
US

V. Phone/Fax

Practice location:
  • Phone: 602-867-8644
  • Fax: 602-795-5698
Mailing address:
  • Phone: 602-494-3656
  • Fax: 602-867-3862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301084825
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number50640
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: