Healthcare Provider Details

I. General information

NPI: 1053637801
Provider Name (Legal Business Name): HINA FATIMA SIDDIQUI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2010
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5959 PARK AVE
MEMPHIS TN
38119-5200
US

IV. Provider business mailing address

8201 W BROWARD BLVD
PLANTATION FL
33324-2701
US

V. Phone/Fax

Practice location:
  • Phone: 901-765-3045
  • Fax:
Mailing address:
  • Phone: 866-884-2904
  • Fax: 800-792-9021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.134449
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS10689
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: