=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912056318
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SIRAJ U SIDDIQI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2007
-----------------------------------------------------
Last Update Date | 09/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 309 11TH ST
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41008-1435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-732-3280
-----------------------------------------------------
Fax | 502-575-6234
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2700 STANLEY GAULT PKWY STE 129
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40223-5176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-253-4900
-----------------------------------------------------
Fax | 502-489-5750
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 28062
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------