Healthcare Provider Details

I. General information

NPI: 1720122914
Provider Name (Legal Business Name): NAVEED SIDDIQUE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 E BOONE ST
TAHLEQUAH OK
74464-3338
US

IV. Provider business mailing address

PO BOX 751
HULBERT OK
74441-0751
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-7700
  • Fax: 918-458-9314
Mailing address:
  • Phone: 918-772-3390
  • Fax: 918-458-9314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number18013
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1376513002
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerNPI FOR CORPORATION
# 2
Identifier100822410D
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: