Healthcare Provider Details

I. General information

NPI: 1366414864
Provider Name (Legal Business Name): SAMEER A SIDDIQUI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

1008 S SPRING AVE RM 1311
SAINT LOUIS MO
63110-2520
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-4440
  • Fax:
Mailing address:
  • Phone: 314-977-3626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2009034594
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: