Basic Information
| Provider Information | |||||||||
| NPI: | 1639456122 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIDDIQUI | ||||||||
| FirstName: | MOHAMMED | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 SPALDING DR | ||||||||
| Address2: | STE 307 | ||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605402261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305272920 | ||||||||
| FaxNumber: | 6305272921 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 SPALDING DR | ||||||||
| Address2: | |||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605406508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305272920 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2011 | ||||||||
| LastUpdateDate: | 08/23/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 263489 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0805X | 036-131386 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 036131386 | 05 | IL | MEDICAID |