Healthcare Provider Details

I. General information

NPI: 1073780037
Provider Name (Legal Business Name): SAMEENA KHAN SIDDIQUI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 05/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2540 N MORELAND BLVD
SHAKER HEIGHTS OH
44120-1375
US

IV. Provider business mailing address

10-1-13/3 A.C . GUARDS, HYDERABAD,
HYDERABAD A.P.
500004
IN

V. Phone/Fax

Practice location:
  • Phone: 312-733-5448
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number57.013365
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: