Healthcare Provider Details

I. General information

NPI: 1609706977
Provider Name (Legal Business Name): MOHAMMED IDREES HASAN SIDDIQUI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2990 MACK ROAD 1RST FLOOR GME ADMIN
FAIRFIELD OH
45014
US

IV. Provider business mailing address

2990 MACK ROAD 1ST FLOOR GME ADMIN
FAIRFIELD OH
45014
US

V. Phone/Fax

Practice location:
  • Phone: 513-870-7800
  • Fax:
Mailing address:
  • Phone: 786-913-9392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: