Basic Information
| Provider Information | |||||||||
| NPI: | 1689672024 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIDDIQUI | ||||||||
| FirstName: | PARVEEN | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 673215 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482673215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867784080 | ||||||||
| FaxNumber: | 5867786055 | ||||||||
| Practice Location | |||||||||
| Address1: | 23411 JEFFERSON AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480801949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867784080 | ||||||||
| FaxNumber: | 5867786055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2005 | ||||||||
| LastUpdateDate: | 04/29/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | PS076755 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4240936 | 05 | MI | MEDICAID |