=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558553263
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMINA SIDDIQUI MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2007
-----------------------------------------------------
Last Update Date | 10/26/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24302 NORTHEN BLVD
-----------------------------------------------------
City | DOUGLASTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11362-1199
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-423-6200
-----------------------------------------------------
Fax | 718-423-9762
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 LINDEN ST
-----------------------------------------------------
City | GREAT NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11021-3841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-804-0457
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | P9960
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------