Healthcare Provider Details

I. General information

NPI: 1285933416
Provider Name (Legal Business Name): ADAM SIDDIQUI R.EPT, CNIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2011
Last Update Date: 10/08/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 1ST ST STE 250
SIMI VALLEY CA
93065-1574
US

IV. Provider business mailing address

2781 ITHACA PLACE
LEWISVILLE TX
75067
US

V. Phone/Fax

Practice location:
  • Phone: 214-972-8151
  • Fax: 877-705-3046
Mailing address:
  • Phone: 214-972-8151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License NumberREPT1104
License Number State
# 2
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License NumberCNIM2124
License Number State
# 3
Primary TaxonomyN
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number2124
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: