Healthcare Provider Details

I. General information

NPI: 1972614436
Provider Name (Legal Business Name): SHOAB SIDDIQUE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 02/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 Q ST
SACRAMENTO CA
95816-7058
US

IV. Provider business mailing address

3400 DATA DR
RANCHO CORDOVA CA
95670-7956
US

V. Phone/Fax

Practice location:
  • Phone: 916-733-3333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberA71415
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: