Healthcare Provider Details

I. General information

NPI: 1467803122
Provider Name (Legal Business Name): OMAR MOHAMMED SIDDIQUI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 EUCLID AVE
CLEVELAND OH
44106-1716
US

IV. Provider business mailing address

460 PRINCE VALIANT LN
BOURBONNAIS IL
60914-9333
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-7603
  • Fax:
Mailing address:
  • Phone: 224-619-2205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125069011
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036149859
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number57248471
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036149859
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036149859
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: