Provider Demographics
NPI:1285933416
Name:SIDDIQUI, ADAM (REPT, CNIM)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:SIDDIQUI
Suffix:
Gender:M
Credentials:REPT, CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2781 ITHACA PLACE
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067
Mailing Address - Country:US
Mailing Address - Phone:214-972-8151
Mailing Address - Fax:
Practice Address - Street 1:2655 1ST ST STE 250
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1574
Practice Address - Country:US
Practice Address - Phone:214-972-8151
Practice Address - Fax:877-705-3046
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-28
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
REPT1104246ZE0600X
CNIM2124246ZE0600X
CA2124156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
No156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Multi-Specialty