Healthcare Provider Details

I. General information

NPI: 1235389875
Provider Name (Legal Business Name): IMRAN A SIDDIQUI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2008
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S ORANGE AVE
ORLANDO FL
32806-2134
US

IV. Provider business mailing address

1400 S ORANGE AVE
ORLANDO FL
32806-2134
US

V. Phone/Fax

Practice location:
  • Phone: 321-842-9097
  • Fax: 321-841-1296
Mailing address:
  • Phone: 321-842-9097
  • Fax: 321-841-1296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number056653
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberU7275
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME165255
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: