Healthcare Provider Details

I. General information

NPI: 1164955936
Provider Name (Legal Business Name): SHEHZAD HASSAN SIDDIQUE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2017
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 W WHITE RIVER BLVD
MUNCIE IN
47304-4286
US

IV. Provider business mailing address

240 N TILLOTSON AVE
MUNCIE IN
47304-3988
US

V. Phone/Fax

Practice location:
  • Phone: 765-288-1928
  • Fax:
Mailing address:
  • Phone: 765-288-1928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01084995A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: