Healthcare Provider Details

I. General information

NPI: 1689672024
Provider Name (Legal Business Name): PARVEEN N SIDDIQUI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 04/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23411 JEFFERSON AVE SUITE 100
SAINT CLAIR SHORES MI
48080-1949
US

IV. Provider business mailing address

PO BOX 673215
DETROIT MI
48267-3215
US

V. Phone/Fax

Practice location:
  • Phone: 586-778-4080
  • Fax: 586-778-6055
Mailing address:
  • Phone: 586-778-4080
  • Fax: 586-778-6055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberPS076755
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: