Healthcare Provider Details

I. General information

NPI: 1346231065
Provider Name (Legal Business Name): FARJAAD SIDDIQ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 WOLF CIR
LAKE CHARLES LA
70605-2353
US

IV. Provider business mailing address

PO BOX 122525 DEPT 2525
DALLAS TX
75312-0001
US

V. Phone/Fax

Practice location:
  • Phone: 337-480-7499
  • Fax: 337-480-7498
Mailing address:
  • Phone: 337-494-2921
  • Fax: 337-494-6523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number15753R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: