Healthcare Provider Details

I. General information

NPI: 1487997284
Provider Name (Legal Business Name): MUSTAFA SIDDIQUE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2013
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 FORT ST STE 200
TRENTON MI
48183-4636
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 734-362-6730
  • Fax: 734-362-6735
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number4301507567
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: