Healthcare Provider Details

I. General information

NPI: 1093750796
Provider Name (Legal Business Name): SHAZ SIDDIQI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44160 SCHOLAR PLZ SUITE 390
LANSDOWNE VA
20176-3459
US

IV. Provider business mailing address

44160 SCHOLAR PLZ SUITE 390
LANSDOWNE VA
20176-3459
US

V. Phone/Fax

Practice location:
  • Phone: 703-938-3900
  • Fax: 703-726-2579
Mailing address:
  • Phone: 703-938-3900
  • Fax: 703-726-2579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number0101250699
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberD0062974
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: