Provider Demographics
NPI:1336274729
Name:SIDDIQUI, NASIRUDDIN A (MD)
Entity type:Individual
Prefix:DR
First Name:NASIRUDDIN
Middle Name:A
Last Name:SIDDIQUI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8011 NEW LAGRANGE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4781
Mailing Address - Country:US
Mailing Address - Phone:502-394-0402
Mailing Address - Fax:502-394-0480
Practice Address - Street 1:8011 NEW LAGRANGE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4781
Practice Address - Country:US
Practice Address - Phone:502-394-0402
Practice Address - Fax:502-394-0480
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY242212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64242217Medicaid
KYC65477Medicare UPIN
KY64242217Medicaid