Healthcare Provider Details

I. General information

NPI: 1861750069
Provider Name (Legal Business Name): OMAR MAHMUD SIDDIQI M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8020 LIBERTY WAY
WEST CHESTER OH
45069-2519
US

IV. Provider business mailing address

8020 LIBERTY WAY
WEST CHESTER OH
45069-2519
US

V. Phone/Fax

Practice location:
  • Phone: 513-777-8300
  • Fax: 513-777-0431
Mailing address:
  • Phone: 513-777-8300
  • Fax: 513-777-0431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35-125374
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: