Healthcare Provider Details

I. General information

NPI: 1598250417
Provider Name (Legal Business Name): SHAN SIDDIQI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2018
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 LINCOLN RD STE 460
MIAMI BEACH FL
33139-2911
US

IV. Provider business mailing address

605 LINCOLN RD STE 460
MIAMI BEACH FL
33139-2911
US

V. Phone/Fax

Practice location:
  • Phone: 310-955-1046
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME150003
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125073032
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: