Provider Demographics
NPI:1174786107
Name:SIDDIQUIE, AMBREEN SAJJAD (MD)
Entity type:Individual
Prefix:
First Name:AMBREEN
Middle Name:SAJJAD
Last Name:SIDDIQUIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 S JUPITER RD
Mailing Address - Street 2:STE 101
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75042-7793
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:804-217-7991
Practice Address - Street 1:1260 TEMPLE AVE
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2984
Practice Address - Country:US
Practice Address - Phone:804-518-2597
Practice Address - Fax:804-518-2598
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP8080207R00000X
VA0101242950207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV3004A - C03895Medicare PIN