Provider Demographics
NPI:1902335524
Name:SIDDIQUI, AZAM
Entity type:Individual
Prefix:
First Name:AZAM
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 1:3511 SCHOONER RDG
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4259
Mailing Address - Country:US
Mailing Address - Phone:678-756-6503
Mailing Address - Fax:
Practice Address - Street 1:65 W JIMMIE LEEDS RD
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:NJ
Practice Address - Zip Code:08240-9102
Practice Address - Country:US
Practice Address - Phone:609-404-3817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA012345002080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine