Healthcare Provider Details

I. General information

NPI: 1073930152
Provider Name (Legal Business Name): DR. MARJILLA SEDDIQ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2014
Last Update Date: 01/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 BARD AVE ROOM 314
STATEN ISLAND NY
10310-1664
US

IV. Provider business mailing address

10412 NELLIE WHITE LN
FAIRFAX VA
22032-3821
US

V. Phone/Fax

Practice location:
  • Phone: 718-818-4636
  • Fax: 718-818-2739
Mailing address:
  • Phone: 703-309-9442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101263319
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: