Healthcare Provider Details

I. General information

NPI: 1710113659
Provider Name (Legal Business Name): ISHRETH FATIMA SIDDIQUI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2009
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 S ZARZAMORA ST
SAN ANTONIO TX
78207-5209
US

IV. Provider business mailing address

PO BOX 87
SAN ANTONIO TX
78291-0087
US

V. Phone/Fax

Practice location:
  • Phone: 210-358-7474
  • Fax: 210-358-7406
Mailing address:
  • Phone: 210-358-9172
  • Fax: 210-358-9183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR1294
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: