Healthcare Provider Details

I. General information

NPI: 1013928142
Provider Name (Legal Business Name): TALHA SIDDIQUI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 05/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6164 FULLER CT
ALEXANDRIA VA
22310-2540
US

IV. Provider business mailing address

6164 FULLER CT
ALEXANDRIA VA
22310-2540
US

V. Phone/Fax

Practice location:
  • Phone: 571-257-9580
  • Fax:
Mailing address:
  • Phone: 571-257-9580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number0101233817
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number0101233817
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: