Provider Demographics
NPI:1679956239
Name:SIDDIQUI, SOPHIA
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:SIDDIQUI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 E CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-6331
Mailing Address - Country:US
Mailing Address - Phone:559-737-4700
Mailing Address - Fax:559-734-1247
Practice Address - Street 1:355 BARD AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-1664
Practice Address - Country:US
Practice Address - Phone:718-818-2419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA160176207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine