Provider Demographics
NPI:1487747010
Name:SIDDIQUI, NASIMUL (MD)
Entity type:Individual
Prefix:DR
First Name:NASIMUL
Middle Name:
Last Name:SIDDIQUI
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:407-876-2273
Mailing Address - Fax:407-347-3950
Practice Address - Street 1:11600 LAKESIDE VILLAGE LN
Practice Address - Street 2:
Practice Address - City:WINDERMERE
Practice Address - State:FL
Practice Address - Zip Code:34786-7024
Practice Address - Country:US
Practice Address - Phone:407-846-2273
Practice Address - Fax:407-347-3950
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71809208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251637300Medicaid
FLM6832OtherFL MEDICARE