Basic Information
| Provider Information | |||||||||
| NPI: | 1265736367 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIDDIQUE | ||||||||
| FirstName: | MUHAMMAD | ||||||||
| MiddleName: | TALAL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6100 HARRIS PKWY | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761324101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172504906 | ||||||||
| FaxNumber: | 8172504815 | ||||||||
| Practice Location | |||||||||
| Address1: | 6100 HARRIS PKWY | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761324101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172504906 | ||||||||
| FaxNumber: | 8172504815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2011 | ||||||||
| LastUpdateDate: | 03/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | P7035 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 327760003 | 05 | TX | MEDICAID |