Healthcare Provider Details

I. General information

NPI: 1548294630
Provider Name (Legal Business Name): ANWER MUKHTAR SIDDIQI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W 8TH ST
JACKSONVILLE FL
32209-6511
US

IV. Provider business mailing address

PO BOX 44008 PROVIDER ENROLLMENT
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-4218
  • Fax: 904-244-4060
Mailing address:
  • Phone: 904-244-4218
  • Fax: 904-244-4060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number17808
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberME113588
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: