Healthcare Provider Details

I. General information

NPI: 1033265665
Provider Name (Legal Business Name): MOHAMMAD SHUJAUDDIN SIDDIQUI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10769 HOLE AVE SUITE 220
RIVERSIDE CA
92505-2808
US

IV. Provider business mailing address

10769 HOLE AVE SUITE 220
RIVERSIDE CA
92505-2808
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-5554
  • Fax: 951-358-5980
Mailing address:
  • Phone: 951-358-5554
  • Fax: 951-358-5980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA63496
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: