Healthcare Provider Details

I. General information

NPI: 1588764310
Provider Name (Legal Business Name): SAMINA IBAD SIDDIQUI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMINA IBAD M.D.

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 09/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W RIVERSIDE DR
AUSTIN TX
78704-1247
US

IV. Provider business mailing address

PO BOX 3548
AUSTIN TX
78764-3548
US

V. Phone/Fax

Practice location:
  • Phone: 512-804-3000
  • Fax: 512-323-9051
Mailing address:
  • Phone: 512-445-7787
  • Fax: 512-440-4059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberM4187
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: