Healthcare Provider Details

I. General information

NPI: 1174919542
Provider Name (Legal Business Name): MOIURI SIDDIQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2015
Last Update Date: 12/14/2022
Certification Date: 12/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 IRVING ST NW DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
WASHINGTON DC
20010-3017
US

IV. Provider business mailing address

110 IRVING ST NW DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
WASHINGTON DC
20010-3017
US

V. Phone/Fax

Practice location:
  • Phone: 202-877-8035
  • Fax: 202-877-5435
Mailing address:
  • Phone: 202-877-8035
  • Fax: 202-877-5435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number316574
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: