Healthcare Provider Details

I. General information

NPI: 1003487018
Provider Name (Legal Business Name): IMRAN AHMED SIDDIQI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 07/09/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26520 CACTUS AVE. RUHS-MC ED BLDG RM. 339
MORENO VALLEY CA
92555
US

IV. Provider business mailing address

13162 58TH ST
EASTVALE CA
92880-4601
US

V. Phone/Fax

Practice location:
  • Phone: 951-486-5912
  • Fax: 951-486-5910
Mailing address:
  • Phone: 847-714-6145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: