Provider Demographics
NPI:1194168252
Name:SIDDIQI, DONISH (MD)
Entity type:Individual
Prefix:
First Name:DONISH
Middle Name:
Last Name:SIDDIQI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 WELLSTAR WAY STE 204
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30114-8929
Mailing Address - Country:US
Mailing Address - Phone:470-267-0110
Mailing Address - Fax:770-999-2229
Practice Address - Street 1:1120 WELLSTAR WAY STE 204
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30114
Practice Address - Country:US
Practice Address - Phone:470-267-0110
Practice Address - Fax:770-999-2229
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY287070207Q00000X
GA80152207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04632711Medicaid
NY04632711Medicaid