Provider Demographics
NPI:1871551788
Name:SIDDIQUEE, MASOOD (MD)
Entity type:Individual
Prefix:DR
First Name:MASOOD
Middle Name:
Last Name:SIDDIQUEE
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 1:2080 EASTSIDE DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013
Mailing Address - Country:US
Mailing Address - Phone:678-625-7800
Mailing Address - Fax:678-625-7888
Practice Address - Street 1:2080 EASTSIDE DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013
Practice Address - Country:US
Practice Address - Phone:678-625-7800
Practice Address - Fax:678-625-7888
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047154207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000821939BMedicaid
G72894Medicare UPIN
GA000821939BMedicaid