Basic Information
| Provider Information | |||||||||
| NPI: | 1972614436 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SIDDIQUE | ||||||||
| FirstName: | SHOAB | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 DATA DR | ||||||||
| Address2: | |||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956707956 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3000 Q ST | ||||||||
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| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958167058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167333333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 02/13/2012 | ||||||||
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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 | 207YX0007X | A71415 | CA | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck |
ID Information
| ID | Type | State | Issuer | Description | 000810579445 | 01 | CA | PHCS | OTHER | 1837078 | 01 | CA | FIRST HEALTH | OTHER | 44530 | 01 | CA | INTERPLAN | OTHER | 7494423 | 01 | CA | CIGNA | OTHER | 00A714150 | 05 | CA | MEDICAID | 7796146 | 01 | CA | AETNA | OTHER | 1294175 | 01 | CA | GREAT WEST | OTHER | A71415 | 01 | CA | BLUE CROSS | OTHER | 079115 | 01 | CA | HEALTH NET | OTHER | 1968751 | 01 | CA | UNITED HEALTHCARE | OTHER | 90138939 | 01 | CA | PACIFICARE | OTHER | MCMG298400 | 01 | CA | WESTERN HEALTH ADVANTAGE | OTHER |