Provider Demographics
NPI:1386662757
Name:SIDDIQUI, SHAHID
Entity type:Individual
Prefix:
First Name:SHAHID
Middle Name:
Last Name:SIDDIQUI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224-D CORNWALL STREET, NW, STE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG, VA
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:44055 RIVERSIDE PARKWAY, SUITE 216
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-5176
Practice Address - Country:US
Practice Address - Phone:703-858-1395
Practice Address - Fax:571-918-4202
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101279176207R00000X
MDD0062123207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1386662757Medicaid
MDI23262Medicare UPIN
MD406296500Medicare ID - Type Unspecified