Healthcare Provider Details

I. General information

NPI: 1457430175
Provider Name (Legal Business Name): MOHAMMED W SIDDIQUI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 07/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 SCHOOL ST
CARROLLTON IL
62016-1436
US

IV. Provider business mailing address

PO BOX 7088
VILLA PARK IL
60181-7088
US

V. Phone/Fax

Practice location:
  • Phone: 217-942-6946
  • Fax: 217-942-9349
Mailing address:
  • Phone: 630-706-0557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036081571
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: