Basic Information
| Provider Information | |||||||||
| NPI: | 1508210808 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIDDIQUI | ||||||||
| FirstName: | JEHANZAB | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1524 S SANGAMON ST UNIT 612 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606082251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303385680 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 765 ELA RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | LAKE ZURICH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600472339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475409949 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2016 | ||||||||
| LastUpdateDate: | 09/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 07001316A | IN | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | 016.005767 | IL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.