Healthcare Provider Details

I. General information

NPI: 1962448902
Provider Name (Legal Business Name): SHAHAB Z SIDDIQUI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 E ANTIETAM ST STE 305
HAGERSTOWN MD
21740-5768
US

IV. Provider business mailing address

324 E ANTIETAM ST STE 305
HAGERSTOWN MD
21740-5768
US

V. Phone/Fax

Practice location:
  • Phone: 301-791-2510
  • Fax: 301-739-7798
Mailing address:
  • Phone: 301-791-2510
  • Fax: 301-739-7798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberD45031
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: