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General NPI Number Information
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NPI Number | 1194116186
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Entity Type | Organization
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Legal Business Name | LAKE HAVASU PRIMARY CARE PLLC
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Dates
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Enumeration Date | 02/11/2015
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Last Update Date | 02/11/2015
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Provider Practice Location Address
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Address Line | 1830 MESQUITE AVE SUITE B
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5885
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Country | US
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Telephone | 928-453-0777
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Fax | 928-453-0778
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Provider Business Mailing Address
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Address Line | 1830 MESQUITE AVE SUITE B
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5885
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Country | US
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Telephone | 928-453-0777
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Fax | 928-453-0778
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Authorized Official
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Title or Position | OWNER/MEMBER/MANAGER
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Name | ESSA J SIDIQI
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Credential | M.D.
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Telephone | 928-453-0777
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 48667
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License Number State | AZ
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