Healthcare Provider Details

I. General information

NPI: 1366513426
Provider Name (Legal Business Name): MOHAMMED NASIRUDDIN SIDDIQUI MD FACS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 NEW YORK RANCH RD
JACKSON CA
95642-9328
US

IV. Provider business mailing address

609 NEW YORK RANCH RD
JACKSON CA
95642-9328
US

V. Phone/Fax

Practice location:
  • Phone: 209-257-0301
  • Fax: 209-257-0302
Mailing address:
  • Phone: 209-257-0301
  • Fax: 209-257-0302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberC51828
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: