Provider Demographics
NPI:1871596700
Name:SIDDIQUI, KAMRAN FASIH (MD)
Entity type:Individual
Prefix:DR
First Name:KAMRAN
Middle Name:FASIH
Last Name:SIDDIQUI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KAMRAN
Other - Middle Name:
Other - Last Name:FASIH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2968
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46515-2968
Mailing Address - Country:US
Mailing Address - Phone:574-296-3200
Mailing Address - Fax:574-296-3392
Practice Address - Street 1:303 S NAPPANEE ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2066
Practice Address - Country:US
Practice Address - Phone:574-296-3307
Practice Address - Fax:574-296-3309
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059787A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200464260Medicaid
IN227950A1Medicare PIN
ING48468Medicare UPIN