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General NPI Number Information
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NPI Number | 1851477186
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Entity Type | Individual
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Provider Name | IMTIAZUDDIN M SIDDIQUI MD
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Gender | Male
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Dates
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Enumeration Date | 10/30/2006
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Last Update Date | 03/27/2013
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Provider Practice Location Address
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Address Line | 510 HAMBURG TURNPIKE SUITE E106
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City | WAYNE
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State | NJ
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Zip | 07470
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Country | US
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Telephone | 973-904-3161
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Fax | 973-904-3168
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Provider Business Mailing Address
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Address Line | 252 WASHINGTON VALLEY ROAD
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City | RANDOLPH
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State | NJ
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Zip | 07869
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Country | US
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Telephone | 973-904-3161
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Fax | 973-904-3163
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | MA041078
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License Number State | NJ
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