Healthcare Provider Details

I. General information

NPI: 1669647889
Provider Name (Legal Business Name): WAJID ALI SIDDIQUI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 TAYLOR ST SUITE 6-F
COLUMBIA SC
29201-2923
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30374-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-296-3273
  • Fax: 803-296-7061
Mailing address:
  • Phone: 803-296-7303
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMT186425
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number34048
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: