Healthcare Provider Details

I. General information

NPI: 1215687363
Provider Name (Legal Business Name): FAHAD SHOAIB SIDDIQUI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 UNIVERSITY BLVD STE 3240
INDIANAPOLIS IN
46202-5149
US

IV. Provider business mailing address

545 BARNHILL DR
INDIANAPOLIS IN
46202-5112
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-7744
  • Fax:
Mailing address:
  • Phone: 317-278-6833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberOS20922
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number02008913A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: